Optimizing Nutrition Therapy This TNT course has been developed to provide you with the knowledge and skills necessary to diagnose and provide appropriate clinical nutrition therapy for malnourished patients or those at risk for malnutrition. Our goal is that you will implement many of the guidelines recommended in this program such as routine nutritional assessment and early nutrition intervention when you return to your medical practice.

Prevalence of Malnutrition Malnutrition occurs frequently in hospitalized patients. It is associated with: Increased complications Prolonged length of stay Higher hospital costs Increased mortality At the beginning of this program, we presented a number of studies documenting malnutrition as a common problem in hospitalized patients and particularly prevalent in the critically-ill. We saw that the nutritional needs of patients are frequently not met, and that there are many medical issues that are associated with malnutrition, such as: Increased complications Prolonged length of stay Higher hospital costs Increased mortality

Nutritional Screening and Assessment Screening identifies and classifies patients at risk for malnutrition Assessment – evaluates nutritional status – biochemical parameters – anthropometric measurements – Subjective Global Assessment (SGA) Nutritional screening should be done to identify patients at risk. Patients found to be at risk for malnutrition should be given a nutritional assessment, either by measuring biochemical and anthropometric parameters or through a Subjective Global Assessment. The SGA is an evaluation tool that allows physicians to incorporate clinical findings and subjective patient history into a nutritional assessment. SGA is a valid evaluation tool that may be easily performed in a doctor’s office or hospital setting. When combined with biochemical parameters and anthropometric measurements, its diagnostic and predictive value is increased.

Early Detection of Malnutrition Patients at risk: History of chronic diseases Psychiatric disorders Gastrointestinal diseases Chronic renal insufficiency Impaired immune function Cancer Diabetes Elderly Chronic renal failure COPD There are many clinical conditions that put patients at greater risk for malnutrition; for example, a history of chronic disease, cancer, diabetes, gastrointestinal disorders, malabsorption, chronic renal insufficiency, chronic obstructive pulmonary disease (COPD), and impaired immune function. It is important to use the skills learned in this course to intervene early with nutrition therapy, since early nutrition intervention can have a significant positive impact on clinical outcomes

Normal Energy Metabolism and Nutritional Needs Nutrients are necessary to sustain life The utilization of nutrients depends on availability (fasting) and the inflammatory response (stress) Energy requirements vary according to clinical condition Caloric distribution varies according to metabolic status In this course, we reviewed nutrients necessary to the human body and their primary metabolic pathways. We emphasized the mechanisms that regulate nutrient uptake and presented the physiological framework for calculating energy needs. We studied two methods for calculating energy expenditure and provided general guidelines to correctly distribute the calories administered to a patient.

Metabolic Response to Starvation and Trauma: Nutritional Requirements The metabolic response to starvation is an adaptive mechanism Nutritional needs increase in trauma The body responds differently to starvation and trauma. Malnutrition is associated with a decrease in metabolic rate, which allows the body to adapt to reduced intake. After trauma, metabolic changes are associated with increased nutritional requirements. If nutritional requirements are not met during trauma, loss of protein and body mass can produce significant deterioration.

Nutritional Requirements Energy – Harris-Benedict Equation x stress factor – “Rule of thumb”: 25 – 30 kcal/kg BW – Indirect calorimetry Protein – Stable patients: 0.8 – 1.0 g/kg BW – Stressed patients: 1.2 – 2.0 g/kg BW Once the physician identifies and evaluates a patient in need of nutrition therapy, the patient’s energy and macronutrient requirements should be determined. In this course we identified two methods for calculating energy requirements; the Harris-Benedict Equation with applied stress factor, and the rule of thumb (25-30 kcal per kg of body weight). Indirect calorimetry is another method for determining energy requirements. Once energy requirements are determined, the other macronutrient needs should be calculated, particularly protein. For stable patients, we recommend using 0.8-1.0 g/kg body weight, and for stressed patients who need additional protein for anabolism, we suggest 1.2-2.0 g/kg body weight.

Nutritional Requirements Lipids – Stable patient: 25% – 30% of calories – Stressed patient: 20% – 35% of calories Carbohydrates – Stable patient: 50% – 65% of calories Diabetes mellitus, hyperglycemia, COPD, hypercapnia, may benefit from –  carbohydrates (about 30% of calories) –  lipids (about 50% of calories) Lipids should normally account for 25%-30% of the total calorie provision and 20%-35% of total calories in stressed patients. Carbohydrates should provide between 50% and 65% of calories unless the patient’s condition requires less (about 30%), such as with COPD, diabetes mellitus, and stress-induced hyperglycemia. Lipid should be about 50% of total calories in these cases.

Nutritional Requirements Vitamins and Minerals – Stable patient: 100% daily recommended intake – Stressed patient: 100% daily recommended intake, (COPD, cancer, antioxidants critical care) – Hepatic patient: BCAA, B Vitamins,  folate Na, Cu, Fe, Mn – Renal failure: Na, K, CI, PO4, Vitamin A – HIV/AIDS: antioxidants, Vitamins B6, B12 Vitamins and minerals should be provided at a level to meet 100% of the daily recommended intake for stable patients. Modifications of this level may confer additional benefits in some disease states. For example, stress, trauma, COPD, and cancer patients may require additional antioxidants. Hepatic patients may need additional branched-chain amino acids, B vitamins and folate but reduced amounts of sodium, copper, iron and manganese. Patients with chronic or acute renal failure should have an intake that is lower in electrolytes and vitamin A to make up for the reduced renal excretion of these micronutrients. Finally, patients with HIV or AIDS may require additional intake of antioxidants as well as some B vitamins.

Early Intervention as Part of Initial Care Enteral Nutrition Oral supplements Tube feeding Parenteral Nutrition Total Peripheral Once nutritional requirements are established, the physician must determine the appropriate mode of nutrition therapy. In this course we have learned that early intervention with optimal nutrition therapy can have a significant impact on improved patient outcomes. We have focused primarily on enteral nutrition therapy, because it is the preferred method for nutritional support. As a general rule, “IF THE GUT WORKS, USE IT!” “If the gut works, use it!”

Parenteral Nutrition Supplies partial or total nutrition through venous access Supplies practically all essential nutrients Metabolic monitoring and changes in solution components are needed to maintain metabolic balance Parenteral nutrition supplies partial or total nutrition through venous access. Parenteral nutrition components supply practically all required nutrients. Metabolic monitoring and changes in solution components are needed to maintain metabolic balance according to the patient’s clinical condition.

Benefits of Enteral Nutrition Therapy Maintains GI tract structure and function Enhances intestinal immune function Reduces bacterial translocation Decreases risk of sepsis Fewer complications than with parenteral nutrition Lower costs Enteral nutrition therapy has specific advantages over parenteral nutrition. Maintains GI tract structure and function Enhances intestinal immune function Reduces bacterial translocation Decreases risk of sepsis Fewer complications than with parenteral nutrition Lower costs These benefits are usually a result of using the normal mechanism of nutrient administration and absorption via the GI tract.

Improved Patient Outcomes Improved wound healing Decreased risk of complications – Nosocomial infection Decreased length of stay Decreased healthcare costs There is documented evidence in the literature of the benefits of nutrition therapy in: wound healing decreased risk of complications reduced length of stay thereby reducing burdensome costs to the healthcare system.

Barriers to Nutritional Intervention Lack of physician awareness Limited physician knowledge of nutrition therapy Minimal support from administration Given the prevalence of malnutrition and the many benefits to patients, why, then, is the provision of nutrition therapy not more common? First of all, physicians are generally unaware of the incidence of malnutrition and its impact on their patient’s health and outcomes of their own treatment. Secondly, most physicians have limited nutrition knowledge, and hospital administrators are unaware of the economic and health benefits of nutrition therapy.

Lack of Physician Awareness Physicians consider this the responsibility of other professionals Nutritional assessment not included by physician as part of the initial history and physical Only considered important when severe malnutrition is evident Nutritional evaluation could be included in patient history and physical exam with minimal effort I would like to explore these barriers in more detail. Why are physicians generally unaware of the incidence of malnutrition and its impact on patient health? Nutrition is generally considered the responsibility of other healthcare professionals, such as dietitians. Therefore, nutrition related actions, such as assessments, are not included in the physician’s routine history and physical exam. As a result, nutrition is only considered when malnutrition is grossly evident. However, physicians can play an important role in identifying patients at risk and providing them with proper nutrition therapy.

Lack of Administrator’s Awareness Administrator’s lack the knowledge of the positive impact that nutrition therapy can have on patient care and in reducing hospital costs. Hospital administrators, in general, are unaware of the positive impact nutrition therapy can have on patient care, decreased length of stay and overall hospital costs. To increase their awareness, we encourage you to present to them the cost-benefit data discussed in this course, which can be augmented by documenting data on the incidence of malnutrition in your institution.

Goals of the TNT Program Improve patient care Give physicians the knowledge to prevent and manage nutrition-related problems. Teach them how to do this early, safely and efficiently. The TNT program has two primary goals: improve patient care, as we firmly believe that nutrition is vital to quality care, and provide physicians with the necessary nutrition therapy knowledge and skills to act early, safely and efficiently.

TNT Program: Next Steps Screening – Establish a nutritional screening and assessment program Standards – Develop guidelines and standards of care for nutrition therapy Intervention – Promote early nutrition therapy In closing, we encourage you to take several actions. First, institute a program of nutritional screening and assessment in your hospital. This will give you a powerful tool with which to convince the hospital administrator of the importance of providing nutrition therapy. Second, collaborate with other physicians and healthcare professionals to establish some standards of care and guidelines for nutrition therapy. Third, promote early enteral nutrition as the preferred method of nutritional intervention whenever possible.

TNT Program: Next Steps Education – Raise awareness and increase knowledge of healthcare team members on importance of nutrition therapy Research – Collect data on the incidence of malnutrition and positive clinical outcomes of nutritional intervention It is important to increase medical awareness of the risks of malnutrition, and to educate other members of the healthcare team, as well as your patients, on the importance of nutrition in maintaining and improving health. Finally, conduct research and expand current knowledge of how nutrition therapy improves patient care and prevents complications.

TNT was sponsored by Abbott Laboratories CONGRATULATIONS! Thank you for your participation and CONGRATULATIONS on completing the TNT program! TNT was sponsored by Abbott Laboratories