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Nutrition Support

Nutrition Support. Ahmed Mayet, Pharm.D Associate Professor King Saud University. Questions. What medical history support that the patient is “at risk” of malnutrition? What physical findings support that the patient is “at risk” of malnutrition?. Nutrition.

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Nutrition Support

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  1. Nutrition Support Ahmed Mayet, Pharm.D Associate Professor King Saud University

  2. Questions • What medical history support that the patient is “at risk” of malnutrition? • What physical findings support that the patient is “at risk” of malnutrition?

  3. Nutrition • Nutrition—provides with all basic nutrients and energy required for maintaining or restoring all vital body functions from carbohydrate and fat and for building up body mass from amino acid.

  4. Malnutrition • Malnutrition—extended inadequate intake of nutrient or severe illness burden on the body composition and function—affect all systems of the body.

  5. Types of malnutrition • Kwashiorkor: (kwa-shior-kor) is protein malnutrition • Marasmus: (ma-ras-mus) is protein-calorie malnutrition

  6. Kwashiorkor • Protein malnutrition - caused by inadequate protein intake in the presence of fair to good calories intake in combination with the stress response • Common causes - chronic diarrhea, chronic kidney disease, infection, trauma , burns, hemorrhage, liver cirrhosis and critical illness

  7. Clinical Manifestations • Marked hypoalbuminemia • Anemia • Edema • Muscle atrophy • Delayed wound healing • Impaired immune function

  8. Marasmus • The patient with severe protein-calorie malnutrition characterized by calories deficiency • Common severe burns, injuries, systemic infections, cancer etc or conditions where patient does not eat like anorexia nervosa and starvation

  9. Marasmus protein-calorie • The patient with severe malnutrition characterized by calories deficiency • Common severe burns, injuries, systemic infections, cancer etc or conditions where patient does not eat like anorexia nervosa and starvation

  10. Clinical Manifestations • Weight loss • Reduced basal metabolism • Depletion skeletal muscle and adipose (fat) stores • Decrease tissue turgor • Bradycardia • Hypothermia

  11. Risk factors for malnutrition • Medical causes • Psychological and social causes

  12. Medical causes(Risk factors for malnutrition) • Recent surgery or trauma • Sepsis • Chronic illness • Gastrointestinal disorders • Anorexia, other eating disorders • Dysphagia • Recurrent nausea, vomiting, or diarrhea • Pancreatitis • Inflammatory bowel disease • Gastrointestinal fistulas

  13. Psychosocial causes • Alcoholism, drug addiction • Poverty, isolation • Disability • Anorexia nervosa • Fashion or limited diet

  14. Consequences of Malnutrition • Malnutrition places patients at a greatly increased risk for morbidity and mortality • Longer recovery period from illnesses • Impaired host defenses • Impaired wound healing • Impaired GI tract function

  15. Cont: • Muscle atrophy • Impaired cardiac function • Impaired respiratory function • Reduced renal function • mental dysfunction • Delayed bone callus formation • Atrophic skin

  16. International, multicentre study to implement nutritional risk screening and evaluate clinical outcome “Not at risk” = good nutrition status “At risk” = poor nutrition status Results: Of the 5051 study patients, 32.6% were defined as ‘at-risk’ At-risk’ patients had more complications, higher mortality and longer lengths of stay than ‘not at-risk’ patients. Sorensen J et al ClinicalNutrition(2008)27,340 349

  17. International,multicentre study to implement nutritional risk screening and evaluate clinical outcome ClinicalNutrition(2008)27,340e349

  18. Metabolic Rate Normal range Long CL, et al.JPEN 1979;3:452-6

  19. Protein Catabolism Normal range Long CL.Contemp Surg 1980;16:29-42

  20. Answer (medical history) What medical history support that the patient is “at risk” of malnutrition? • Nausea • Abdominal pain • Diarrhea • Loss of appetite • Weight loss

  21. Answer (physical finding) Cont; What physical findings support that the patient is “at risk” of malnutrition? • Pale • Lethargic • Muscle wasting • cachecxia • Edematous • Hypotensive • Tachycardia • Burses and patichiae on the limbs

  22. Question • What biochemical, anthropometric, indirect calorimetric, and other testes are suggesting that your patient is malnourish?

  23. Cont: • The initial assessment of nutritional status requires a careful • History • Physical examination • Laboratory and other tests

  24. Laboratory and other tests • Weight • BMI • Fat storage • Somatic and visceral protein

  25. Standard monogram for Height and Weight in adult-male

  26. Percent weight loss 129 lbs – 110 lbs = 19 lbs 19/129 x 100 = 15% 139 lbs – 110 lbs = 29 lbs 29/139 x 100 = 20% 50kg x 2.2 = 110 lbs Small frame Medium frame

  27. Severe weight lost

  28. Laboratory and other tests • Weight • BMI • Fat storage • Somatic and visceral protein

  29. Average Body Mass Index (BMI) for Adult Our patient BMI = 16.3 kg/m2

  30. Laboratory and other tests • Weight • BMI • Fat storage • Somatic and visceral protein

  31. Fat • Assessment of body fat • Triceps skinfold thickness (TSF) • Waist-hip circumference ratio • Waist circumference • Limb fat area • Compare the patient TSF to standard monogram

  32. Laboratory and other tests • Weight • BMI • Fat storage • Somatic and visceral protein

  33. Protein (Somatic Protein) • Assessment of the fat-free muscle mass (Somatic Protein)Mid-upper-arm circumference(MAC)Mid-upper-arm muscle circumference Mid-upper-arm muscle area Compare the patient MAC to standard monogram

  34. Protein (visceral protein) Cont; Assessment of visceral protein depletion • Serum albumin <3.5 g/dL • Serum transferrin <200 mg/dL • Serum cholesterol <160 mg/dL • Serum prealbumin <15 mg/mL • Creatinine Height Index (CHI) <75% Our patient has albumin of 2.2 g/dl

  35. Creatinine-height index (CHI ) • [measured urinary creatinine (24hr)/ Ideal urinary creatinine for a given height] • Ideal Cr = IBW x 23 mg/kg male • = IBW x 18 mg/kg female • CHI > 80 mild depletion • CHI 60 – 80 moderate • CHI < 60 severe Assuming that our patient IBW 59 kg (from chart) 990mg/ 59 kg x 23 = 73% (mild depletion)

  36. Vitamins deficiency • Vitamin Bs (B1,B2, B6, B 9, B12, ) • Vitamin C • Vitamin A • Vitamin D • Vitamin K

  37. Trace Minerals deficiency • Zinc • Copper • Chromium • Manganese • Selenium • Iron

  38. Folate, iron, vitamin B12, copper *Pallor *Bruising Vitamin C, vitamin K *Our patient

  39. *Edema Protein, thiamine *Hyporeflexia Thiamine *Spooning Iron

  40. Estimating Energy/Calorie

  41. BEE • Basal Metabolic Rate (BMR) or Basal Energy Expenditure (BEE) accounts for the largest portion of total daily energy requirements

  42. Total Energy Expenditure • TEE (kcal/day) = BEE x stress/activity factor

  43. BEE • The Harris-Benedict equation is a mathematical formula used to calculate BEE

  44. Harris–Benedict Equations • Energy calculation Male • BEE = 66 + (13.7 x actual wt in kg) + (5x ht in cm) – (6.8 x age in y) Female • BEE = 655 + (9.6 x actual wt in kg) + (1.7 x ht in cm) – (4.7 x age in y)

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