DIETETICS AN APPRECIATION JO OLIVER SENIOR I DIETITIAN BIRMINGHAM HEARTLANDS AND SOLIHULL NHS TRUST (TEACHING)

To provide an overview of the dietitians role in the clinical setting. Aim To provide an overview of the dietitians role in the clinical setting.

Objectives By the end of this session you will be able to: Appreciate the dietitians role in the clinical setting. Understand the importance of therapeutic diets and nutritional support.

Objectives (cont) Understand how malnutrition is identified. Appreciate how the dietitian aims to improve nutritional status. Acknowlegde the importance of dietetic monitoring and how this takes place.

What is the Dietitian’s role? Dietitians translate the science of nutrition into practical information about food. Dietitians work in hospitals, community or industry.

Dietetics Specialities include nutrition support, diabetes, gastroenterology, cystic fibrosis, health promotion and sports nutrition. State registration indicates approved training and legally recognised qualification. Evidence based.

Therapeutic diets Diabetes; low sugar, low fat, mediterranian diet. Coeliac disease; gluten free diet. Inflammatory Bowel Disease; low residue diet if mechanical strictures. Acute pancreatitis; elemental diets.

Therapeutic diets Renal disease; low electrolyte, low phosphate depending on biochemistry. Liver disease; low salt, high calorie.

Nutritional support Aim is to treat and prevent undernutrition. Poor nutritional status. Poor and inadequate nutritional intake. Weight loss. Aim is to treat and prevent undernutrition.

Malnutrition Often an unrecognised risk in surgical patients(Hill et al 1977). Up to 40% of patients malnourished on admission(Pennington et al 1994). Nutritional status often deteriorates in hospital(Hungry in hospital 1999).

Malnutrition complicates illness Mental changes - apathy, loss of concentration, depression. Further loss of appetite. Respiratory and cardiac muscles affected due to loss of lean tissue mass(Hill GL,Windsor 1988).

Malnutrition continued Mobility affected leading to increased risk of pressure sores and thrombosis. Impaired immune response leading to an increased risk of infection.

Identifying malnutrition Assessing the patient Obtain/ assess weight. Obtain height/ demispan. Calculate BMI. Complete Nutrition Risk Score(individual to hospital or trust). Complete food record chart.

Improving nutritional intake Food; encouragement, appropriate foods and utensils, correct positioning of the patient. Supplements; fortification of foods, sip feeds (milk or fruit juice based) e.g entera, ensure plus, enlive, fortijuce.

Improving nutritional intake Enteral feeding; NG, NJ, PEG, PEJ. Parenteral Nutrition; Only when gut not available.

Enteral nutrition Nutrition provided via the gastrointestinal tract. Includes nutrition taken orally or administered via an enteric tube. Maintains intestinal structure and function(Thomas 1994).

Enteral nutrition More cost effective and safer in most patients(Thomas1994). Decision and route of feeding decided by medical team in liason with multidisciplinary team. Views of family considered if patient unable to participate in discussions.

Enteral nutrition Decision to enterally feed should be taken in the patients best interests and documented in medical notes by medical staff. In stopping a patients feed, in persistent vegetative states, - court agreement necessary.

Enteral nutrition Certain drugs interact with enteral feeding making the drugs less effective e.g Phenytoin requires a 2hr feeding break pre and post feeding.

Enteral nutrition Refeeding syndrome can occur when feeding malnourished patients by oral, enteral or parenteral route.Consequences include altered glucose metabolism,hypophosphataemia, hypokalaemia(PENG 2000).

Dietetic monitoring Tolerance of enteral feeding; NG aspirates, abdominal distension, bowel function( n.b antibiotics). Biochemistry and fluid balance;fluid balance charts, urea and electrolytes, blood sugars.

Dietetic monitoring Nutritional assessment; weight, anthropometrics, nutritional intake versus estimated requirements. Nutritional requirements based on patients age, sex, height, weight, activity and physiological stress(Elia 1995).

Biochemical monitoring in some therapeutic diets Inflammatory Bowel Disease - CRP, inflammatory markers. Liver disease - LFTS, sodium,albumin.

Biochemical monitoring in some therapeutic diets Coeliac disease - endomysial antibodies, gliadins, IgA. Cystic Fibrosis - vitamins A,D and E, faecal fats. Renal disease - potassium, phosphate, urea.

Parenteral Nutrition Only absolute with a non functioning gut. Proven value in Short Bowel Syndrome, enterocutaneous fistula, high output fistula. Little benefit < 7-10 days.

Parenteral Nutrition Monitoring includes daily weights, fluid balance, urea and electrolytes,blood glucose 6- 8hrly Once requirements assessed discussion with nutrition team to decide on formulation that is practical, safe and stable.

To conclude Dietary manipulation is involved in the management of many conditions. Therapeutic diets and/ or nutritional support often indicated. The dietitian makes dietary assessments, identifies changes that may be required in the diet and tailors advice to the individual.

Conclusion (cont) Dietitians are involved routinely in research. A team approach is essential in strengthening and supporting dietetic input.

References Elia, 1995 Lancet (345) 1279-84. Hill GL, Windsor JA 1988. Weight loss with physiological impairment - a basic indicator of surgical risk. Ann. surgery (207) 290-296. Hill GL,Pickford I, Young GA et al, 1977 Malnutrition in surgical practice- an unrecognised problem. Lancet 689-92.

References (cont) Hungry in Hospital 1999. Association of community health councils for England and Wales. PENG lecture notes year 2000. Pennington CR, McWhirter JP 1994. Incidence of malnutrition in hospital. BMJ (308) 945- 948. Thomas B, 1994 Manual of Dietetic Practice, Blackwood Science.