Nutrition 101: When, What, How to Feed - PowerPoint Presentation

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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

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Nutrition: Why should we care….

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

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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.

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Nutrition in GI Disease:

Nutritional Status

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Nutritional Assessment

Food and Nutrition related historyMedical, Surgical, and Social historyAnthropometric measurementsNutrition 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.

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Food and Nutrition Related History

Dietary intake: 24 hour recallUse of dietary supplementsEating difficulties : poor dentition, taste disturbances, dysphagiaGastrointestinal complaints: Nausea, vomiting, abdominal pain, diarrhea, constipation

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Medical History

Critical illness or chronic diseasePancreatic insufficiencyIBDCeliac disease

Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency.

Journal of Parenteral and Enteral Nutrition

. 2002;26(5):S29-S33.

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Surgical History

Major abdominal surgery, traumaPrevious GI surgeryFistula, 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.

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Social History

Living environmentCaregiverFunctional statusAlcohol or substance abuseMental health

Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency.

Journal of Parenteral and Enteral Nutrition

. 2002;26(5):S29-S33.

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Anthropometric Measurements

HeightWeightUsual Body Weight (UBW)Weight loss

10 lbs. weight loss over 6 months is noteworthy

>10% of UBW

BMI

<

18.5 underweight

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Nutrition focused PE findings

Loss of muscle mass and subcutaneous fatEdema 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.

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Physical Signs

Signs

Deficiencies

Alopecia

Protein

energy malnutrition

Brittle

Hair

Biotin

Follicular

keratosis

Vitamin A

Ecchymosis

Vitamin

C or K

Seborrheic

dermatitis

Vitamin B2, Niacin,

Vitamin B6

Spoon-shaped

nails

Iron

Cheilosis

Vitamin B2, Vitamin B6

Bleeding gums

Vitamin C

Glossitis

Niacin, Folate, Vit B12, Vit B2, Vit B6Magenta TongueVitamin B2Loss of DTRsVitamins B1 and B12

Phillips, SM. Jensen, C. Micronutrient deficiencies associated with malnutrition in children.

In:

UpToDate

,

Motil

, KJ

(Ed),

UpToDate

, Waltham, MA. (Accessed

on April

30, 2014).

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Poor nutrient intake and excessive losses may contribute to malnutrition.

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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

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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

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Assessment: Is this patient malnourished?

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Nutrition in GI Disease:

Nutrition Support

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Nutrition Intervention

Oral nutrition supplementsEnteral NutritionParenteral Nutrition

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Nutrition Support

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Enteral Nutrition Support

Functioning GI tractShort vs. Long TermNG/NJ vs. PEG/PEJGastric: Bolus feedings

Jejunal

: Continuous feedings

Disease Specific Formulas

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Parenteral Nutrition Support

Non-functioning GI tractCentral or PICCEN vs. PN (Complications)

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Nutrition Support

Multi-disciplinary teamRefeeding Syndrome

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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.

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Prognosis of Short Gut Syndrome (SGS)

Presence of residual underlying diseaseLength of remaining small intestinePresence 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

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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

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Bowel Adaptation SGS

Gastric hypersecretionIncreased

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

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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

osmotically

active 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

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Short Gut Syndrome MNT

Hypomotility agentsRotating antibioticsEnzyme replacement

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Short Gut Syndrome

Site

Nutrient

(s) absorbed

Stomach

Cu, I

Duodenum

Fe, Zn, Cu, Se,

Vit

D, E, K, B1, B2, B3,

folate

,

Ca

Jejunum

Zn, Se, Fe,

Ca

, Cr,

Mn

,

Vit

A, D, E, K, B1, B2,

B3, B5, B6,

folate

,

Vit

C

Ileum

Vit C, D, K, B-12, folateShortgutsupport.com

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Nutrition in GI Disease:

Nutritional Therapy

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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 negativeEndoscopic evaluation unremarkable

Micronutrient deficiencies: Calcium, Zinc, Vitamin D, B12

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Nutrition and RYGB Malabsorption

Many patients stop supplements after bariatric surgeryLook for other micronutrient deficienciesOften subtle deficiencies are asymptomatic

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Nutrition and Malabsorption

HypoalbuminemiaSteatorrheaFe deficiency anemiaB 12 deficiency

Thiamine deficiency

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Nutritional Therapy

60-120 grams of protein dailyLong-term vitamin/mineral supplementationPeriodic 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.

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Biochemical Monitoring

6, 12, 18, 24 months then annuallyFe, 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.

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Dietary modifications

Consume small frequent mealsAvoid ingestion of liquids within 30 min of solid foodAvoid simple sugarsIncrease 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.

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Case Study # 4

26-year-old male with ileocolonic Crohn’s disease presents with fatigue, low energy and weight loss. Iron, B 12 and Vitamin D deficiency

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Nutrition and IBD

Nutrient deficiencies Hypoalbuminemia Fe

B12

Vitamin D

Folic acid

Calcium

Magnesium

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Nutritional Therapy

Vitamin/Mineral RepletionElimination DietLactose FreeLow ResidueProbiotic

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Case Study # 5

23-year-old female with history of Type I DM presents with bloating, flatulence, and diarrhea in the setting of anemiaPositive celiac serology with duodenal biopsy c/w villous atrophy

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Nutrition and Celiac Disease

Micronutrient deficienciesPancreatic insufficiency

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Gluten-free diet

Eliminates wheat, rye, and barleyRice, corn, millet, potato, buckwheat, and soybeans are safeCommon gluten free foods

fresh fish, meats, milk, cheese, fruits,

vegetables

Gluten-free substitutes are often expensive and may be difficult to access

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Management of Celiac Disease

C

Consultation with a skilled

dietitian

E

Education about

the disease

L

Lifelong adherence to a gluten-free

diet

I

Identification

and treatment of nutritional deficiencies

A

Access to an advocacy group

C

Continuous long-term follow-up by a multidisciplinary

team

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.

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Nutrition in GI Disease:

Nutritional Therapy

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Nutrition and IBS

Multifactorial: visceral hypersensitivity, gut flora, diet

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Nutritional Therapy

Lactose Free dietProbioticsFiber Supplements (Psyllium)FODMAP Diet

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FODMAP

Fermentable OligoDiMonosaccharides and Polyols

Poor absorption

Osmotic effect

B

acterial fermentation

Simren M. Diet as a Therapy for irritable bowel

s

yndrome: progress at last.

Gastroenterology

. 2014;146(1):10-12.

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Absorption of FODMAPs

Presence or absence of enzymesSmall 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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FODMAP Diet

Fedewa

A,

Rao

S. Dietary Fructose Intolerance,

Fructan

Intolerance and FODMAPS

.

Current Gastroenterology Reports

. 2014;16(1):370.

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FODMAP Approach

Barrett, J. Extending our knowledge of Fermentable, Short-Chain Carbohydrates for Managing Gastrointestinal Symptoms.

Nutrition in Clinical Practice

. 2013;28(3):300-306

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FODMAP Approach

Provides therapeutic strategy to manage symptoms.Use of dietitian is paramount.Address long-term efficacy and safety of dietary intervention.

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Nutrition and GERD

Chronic acid exposureReflux triggering foodsSpicy

Acidic

Citrus

Fried/Fatty

Caffeine, coffee, cola

Spearmint/Peppermint

Chocolate

Alcohol

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Nutritional Therapy

Dietary/Behavioral ModificationsAvoidance of reflux triggering foodsSmall frequent meals throughout the day

Avoid tobacco use

Avoid tightly fitting clothing

Raise head of bed 6-9 inches

Stay upright 2-3 hours after meals

H2 blockers/PPIs

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Nutrition and Gastroparesis

Hypomotility disorderEtiology: Idiopathic, post-viral, diabetic

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Nutritional Therapy

Dietary/Behavioral ModificationsSeveral small frequent mealsAvoid high fat and fiber foods

Chew food slowly/thoroughly

Sit upright

Active

Digestive Enzymes/Probiotics

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Nutrition and Eosinophilic

EsophagitisChronic allergic diseaseElimination diet

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Nutritional Therapy

Six-Food-Elimination DietMilkEggs

Nuts

Wheat

Fish/Shellfish

Soy

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Therapeutic Approach

Treat underlying etiologyDietVitamin/Mineral supplementation

Nutrition support

Pharmacotherapy

If underlying etiology is irreversible-target symptoms

Anti-diarrheal

PERT

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In Summary

Recognize nutrition is apart of most of what we do as GI specialistsUnderstand the impact of GI disease on nutritional status Utilize a nutrition assessment to dictate intervention

Consult with a dietitian

Work with multi-disciplinary team