Medical Nutrition Therapy Exam Study Guide #1.doc

29 Pages

Course Code
NUTR 427
Gene Cerami

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Intake: Analysis of the Diet Nutritional Status Mirrors the degree to which physiologic nutrient needs are met for an individual. The balance between nutrient intake and nutrient requirements equals that nutrition status. • A measurement of the degree to which the individuals physiologic need for nutrients is being met. • When the adequate amount of nutrients are consumed to support the bodies daily needs including any increased metabolic demands. The person moves towards optimal nutrition status. • An individual with adequate intake promotes growth and development, maintains general health and supports activities of daily leaving and helps protect the body from disease and illness. 1 Optimal Nutrition Status viewed as a balance. Nutrition Imbalance Nutrition is an important factor in the etiology and management of several major causes of death and disability. • Heart disease, strokes, diabetes, most cancers are influenced by the type and amount of food consumed. States of nutrition deficiency or excess occur when nutrient intake does not match individual’s requirements for optimal health. • Within the safe range of intake, homeostatic mechanisms allow the body to use nutrients equally effectively, with no detectable advantage gained by a specific intake. As deficiencies or excesses develop adaptation are made to achieve a new steady state without any significant loss in physiological function. As the intake departs further from the desirable range the organism accommodates to the changing supply of nutrients reducing the function, size, or status of the affect body compartments. The Nutritional status of an individual is identified by the success or failure of these adaptations. o Example: before iron deficiency anemia is diagnosed from measures of hematocrit, hemoglobin, and clinical signs, a gradual diminution in iron stores can be diagnosed on the basis of increased iron absorption, decreased serum ferritin levels or bone marrow evaluation. Under nutrition: When nutrition reserves are depleted or intake is inadequate to meet daily metabolic needs. Which can stem from inadequate ingestion, impaired digestion or absorption, dysfunctional metabolic processing or increased excretion of essential nutrients. • Infants, children, pregnant woman, individuals with low incomes, hospitalized person, and older adults are at the greatest risk. • Impaired growth and development, lowered resistance to infection delayed wound healing, poor clinical outcome from disease or trauma, development of chronic disease and increased morbidity and mortality may result. Overnutrition: manifests in obesity, diabetes, atherosclerotic heart disease, hypertension, and the metabolic syndrome. 2 • Obesity is associated with low-grade inflammation, high levels of inflammatory markers such as C-reactive protein and proinflammatory cytokines. Nutrition Screening The components of nutrition screening may slightly vary from some setting to another but the tools should be simple and easy to complete. They must also be reliable and measure what they are support to measure. Purpose: to quickly identify individuals who are malnourish or at nutritional risk and to determine if a more detailed assessment is warranted. • Characteristics of Nutrition Screening o Simple and easy to complete o Routine data o Cost effective o Effective in identifying nutrition problems o Reliable and valid 3 • The most common screening includes history of weight loss, current need for nutrition support, skin breakdown, poor intake, and chronic use of modified diets. o Information collected during a nutrition screen depends on 1. The setting in which the information was collected 2. The life stage or disease type 3. Available data 4. A definition of risk priorities 5. The goal of the screening process o Regardless of the data the goal of the screening is to identity people who are at nutritional risk and those that are likely to become at risk and who need further assessment.  Example: being 85 years or older, having low nutrient intake, losing the ability to eat independently, having swallowing and chewing difficulties, becoming bedridden. Malnutrition Screening Tools • Malnutrition Screening tool MST : o Very affective, last 6 months. o 2 questions. • Mini Nutritional Assessment Short Form MNA (4.4) o Older patients, tool includes both a screening section and assessment section. The screening portion contains questions related to food intake, weight loss, mobility, stress, neuropsychological condition and BMI. 6 questions. • Malnutrition Universal Screening Tool MUST (4.3) o Designed to be used by multiple disciplines. Three criteria are used: current weight and height and BMI. Unintentional weight oss using specific cut off porints and acute diease effect on nutrition intake for greater than 5 days o Scores are added and put into categories. • Nutritional Risk Screening 2002 • Short Nutritional Assessment Qustionnaire Nutrition Assessment : First Step of the Nutrition Care Process 4 Comprehensive evaluation to define nutritional status using medical social nutritional and medication histories, physical examinations, anthropometric measurements and laboratory data. • Appropriate assessment technique can detect a nutritional deficiency in the early stages of development allowing dietary intake to be improved through nutrition support and counseling before a more severe condition develops. • Personal intake is influences by factors such as economic situation, eating behavior, emotional climate, cultural influences, effects of disease states on appetite, and the ability to acquire and absorb nutrients. • Nutrient requirements are influenced by genetics, physiologic stressors such as infection, acute or chronic disease processes, fever, trauma; anabolic states such as pregnancy, childhood or rehabilitation; overall body maintenance and psychological stress. • One the nutrition assessment process is complete and a nutritional diagnosis made, the plan of care can be developed Once interventions are chosen they can be tailored for the appropriate setting. Screening and assessment are integral parts of nutrition care. The accepted nutrition care process (NCP) has 4 steps 1. Assessment of Nutrition Status 2. Identification of Nutritional diagnoses 3. Interventions such as goal setting food and nutrient delivery, education, counseling, coordination of care 4. Monitoring and evaluating of the effectiveness of the interventions. Goals 1. Identify individuals who require aggressive nutritional support 2. Restore or maintain nutrition wellness 3. Identify appropriate medical nutrition therapy 5 Clinical: Inflammation, Physical, and Functional Assessments 18/10/2013 21:39:00 Clinical Inflammation Physical and Functional Assessments. Inflammation is a protective response by the immune system to infection, acute illness, trauma, toxins, many chronic disease and physical stress. When inflammation is present, acute phase proteins CANNOT be used as markers of dietary intake. • Acute inflammation reactions are short term because of the involvement of negative feedback mechanisms. • Chronic inflammation begins as a short term process but is not extinguished. The body continues to synthesize inflammatory mediators which alter normal physiological processes and affect innate immunity. o Loss of barrier function, responsiveness to normal benign stimulus, infiltration of large number of inflammatory cells, overproduction of exidants, cytokines, chemokines, eicosanoids, and matrix metalloproteinases all contribute to disease onset and progression.  Example: isulin resistance in the setting of ebestity results from a combination of altered functions of insulin target cells and the accumulation of macrophages that secrete proinflammatory mediators which can promote the metabolic syndrome. Inflammatory conditions trigger the immune response to release eicosanoids and cytokines which mobilize nutritents required to synthesize positive acute phase proteins and white blood cells. • Cytokines, tumor necrosis factor alpha, interleukin-6, and eicosanoids influence whole body metabolism, body comp, and nutritional status. • Cytokines reorient hepatic synthesis of plasma proteins and increase the breakfown of muscle protein to meet the demand for protein and energy during the inflammatory response. o There is a redistribution of albumin the interstitial compartment, resulting in edema. 6 • Declining values of negative acute-phase proteins indicate inflammation is present. o Positive Acute Phase Reactants: 1. C-reactive protein 2. a-1 antichymotrypsin 3. a1-antitrypsin 4. haptoglobins 5. ceruloplasmin 6. serum amuloid A 7. Fibrinogen 7 8. Ferritin 9. Complement and compnents c3 and c4 10. Orosomucoid o Negative Acute Phase Proteins  Decrease during inflammation.  Albumin  Transferrin  Prealbumin  Retinol binding protein Improvements in albumin, prealbumin, and transferring most likely reflect a change in hydration status rather than increased protein and energy intake. Cytokines impair the production of erythrocytes and reorient iron stores from hemogolin and serum iron to ferritin. During infection IL-1B inhibits the production and release of transferring while stimulating the synthesis of ferritin. • Lab test results used to predict the risk of nutrition anemias are not useful in assessing the patient with an inflammatory response. As the body responds to acute inflammation hepatic synthesis of positive acute phase proteins diminish and synthesis of negative acute phase proteins increase. Albumin shifts from interstitial compartment to the extravascular space. Iron stores shift from ferritin to transferrin and hemoglobin. Inappropriate synthesis of inflammatory mediators can be triggered by an injury reactive oxygen species or abnormal levels of body components such as glucose or visceral adipose tissue. Chronic inflammation is present in crohn disease, rheumatroid arthritis cardiovascular disease, and obesity. B cells help to regulate cellular immune response and inflammation. 8 Clinical: Biochemical Assessment 18/10/2013 21:39:00 Definitions and Usefulness of Nutrition Lab Data 9 Laboratory tests are ordered to diagnose disease, support nutrition diagnoses, monitory medication effectiness and evaluate nutrition care process interventions. They can provide objective data to use in the NCP. Laboratory assessment is a stringently controlled process. It involves comparing control samples with predetermined substance or chemical constituent (analyte) concentrations with every patient specimen. The lab data are the only objective data used in the nutritional assessment that are controlled, the lab value is known. Lab-based nutritional tested is used to estimate nutrient availability in biologic fluids and tissues. Is critical for assessment of both clinical and subclinical nutrient deficiencies. Single test results must be evaluated in ight of the patients current medical conditions medications, life style choices, age hydration status, fasting status at the time of specimen collection. Reference standards used by the clinical laboratory. Changes in the lab test results that occur over time are often an objective measure of nutrition or pharmacologic intervention Specimen Type a. Whole blood: collected with an anticoagulate if entire content of blood is being evaluated. Contains RBC’s, WBC’s and platelets suspended in plasma. b. Serum: the fluid obtained from blood after the blood has been clotted and then centrifuged to remove the clot and blood cells c. Plasma: transparent (straw colored) liquid component of blood, composed of water blood proteins inorganic electrolytes and clotting factor. d. Blood cells: separated from anticoagulated whole blood for measurement of cellular analyte content e. Erythrocytres: RBCs f. Leukocytes: WBCs and fractions of LC 10 g. Blood Spots: dried whole blood from finger or heel prick that is placed on paper and can be used for selected hormone tests and other tests such as infant phenylketonuria screening. h. Other tissues: obtained from scrapings or biopsy i. Urine: contains a contentrate of excreted metabolites j. Feces: important in nutritional analyses when nutrients are not absorbed and therefore re present in fecal material or to determine composition of gut flora. k. Breath tests: evaluate nutrient metabolism, use, and malabsorption. Particularly in sugars. l. Hair and nails: easy to collect for determining exposure to toxic metals, poor indicator of actual body levels of nutritents, potential for contamination. Hair may be helpful in assessing levels of trace elements such as zinc, copper, chromium, and manganese. m. Saliva: fast turnover currently is used to evaluate functional adrenal stress and hormone levels n. Sweat: electrolyte test used to detect sweat chloride levels to determine presence or cystic fibrosis. Assay Types Two fundamental types of lab assay are static assays and functional assays. • Static: measure the actual level of nutrient in the specimen. o Direct and specific o Although this kind of assay is absolutely specific for the nutrient of interest, specimen nutrient concentrations do not reflex the amount of that substance stored in body pools that are not samples. o Another major limitation of static assays is that recent dietary intake influences the among of nutrient found in serum, plasma, or any other fluid or tissue.  This problem can be overcome at least partially by collecting the specimen following an overnight fast. • Functional: quantitatively measure a biochemical or physiological activity that depends on the nutrient of interest. This type of assay can be very senstitive for a nutrient at its functional site. 11 o Example: serum ferritin: the concentration of ferritin released into the blood is a function of the iron present in the cellular storage pool.  Unfortunately functional assays are not always specific for the nutrient of interest because many physiologic and biochemical functions depend on various biological factors in addition to the specific nutrient. Medical Laboratory Panels Clinical Chemistry Panels • Basic Metabolic Panel (BMP) i. Glucose ii. Calcium iii. Sodium iv. Potassium v. CO2 vi. Chloride vii. BUN viii. Creatinine • Comprehensive Metabolic Panel o Glucose o Calcium o Sodium o Potassium o CO2 o Chloride o BUN o Creatinine o Albumin o Total Protein o ALP o ALT o AST 12 o Bilirubin Complete Blood Count (CBC) Provides a count of cells in the blood and description of the RBCs. A hemogram is a CBC with a while blood cell differential count. Stool Testing Fecal samples may be tested for the presence of blood pathogens and gut flora. Routinely order for adults older than 50 and young adults with unexplained anemia. • Patients with chronic gastrointestinal symptoms such as maldigestion or unexplain weight loss or gain may benefit from gut flora testing to identify pathologic flora or an imbalance of physiologic flora. Urinalysis Used as a screening or diagnostic tool to detect substances or cellular material in the urine associated with different metabolic and kidney disorders. • The full urinalysis includes a record of o The appearance of the urine o The results of basic tests done with chemically impregnated reagent strips that can be read visually or by an automated reader. o The microscopic examination of urine sediment. • Chemical Tests Preformed o Specific Gravity o pH o Protein o Ketones o Blood 13 o Bilirubin o Urobilinogen o Nitrite Leukocyte esterase Assessment of Hydration Status Disorders of fluid balance include dehydration and overhydration. • Dehydration is a state of negative fluid balance caused by decreased intake, increased losses and fluid shifts. • Overhydration (edema) occurs when there is an increase in the extracellular fluid volume. o It is caused by an increase in capolary hydrostatic pressure or capillary permeability, a descrease in colloid osmotic pressure or physical inactivity. • Labs that measure hydration status include serum sodium, blood urea nitrogen, serum osmolality and urine specific gravity. Biochemical Impedance Analysis BIA estimates body comp based on the difference in electrical conductive properties of various body tissues. BIA instruments automatically calculate total body water, fat-free mass, and percent body fat. • Normal hydration is critical for results to be valid. • Individuals who are overhydrated have a lower percent of body fat and a dehydrated individual has an elevated reading for percent body fat. Assessment of Stress-related protein-energy malnutrition Acute illness or trauma causes inflammatory stress. Hormones and cell- medicated responses trigger the breakdown of lean body mass to synthesize cytokines, positive active phase proteins, lactic acid and white blood cells • Evaluation of nutrition status of acutely ill patients exhibiting inflammatory stress is difficult because none of the standard lab test results consistently reflect changes in protein status at either the onset of illness or refeeding. • It however is clear that cutely ill patient loses proteins rapidly because of the inflammatory process. 14 • The following measures should be interpreted cautiously as components of nutritional status because stress changes parameters and values may not reflect nutritional intake of protein accurately. 1. C-Reactive Protein (Inflammation marker) Use of inflammatory biomarkers such as CRP helps to identify when the acute hypermetabolic period of the inflammatory response wanes. Hs-CRP is sensitive measure of chronic inflammation seen in patients with atherosclerosis and other chronic diseases. CRP increases in the initial stages of acute stress, usually within 4 to 6 hours of surgery or other trauma. When CRP levels begin to decrease the patient has entered the anabolic period of the inflammatory response when more intensive nutrition therapy may be beneficial. 2. Creatinine (break down of muscle creatine) • Formed from creatine found almost exclusively in muscle tissue. • Serum creatinine is used along with BUN to assess kidney function. • Urinary creatinine ha been used to assess comatic protein status. • Creatine phosphate is a high energy phosphate buffer that provides a constant supply of ATP for muscle contration. • Urinary creatinine to assess somatic protein status is not as accuate because of high meat diets. The tests can not tell a difference from the creatinine in our bodies and the ones that come from meat. • Men generally have higher levels and excrete larger amounts of creatinine than women. • Daily creatinine excretion varies significantly within indivudals because of sweat loss. In addition the test is based on 24 hour collects. Because of these limitations UCC as a marker of muscle mass has limited use in health care settings and is used manly for research. 2. Immunocompentence 15 • Protein-energy malnutrition is associated with impaired immunocompetence including depressed cell mediated immunity,
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