Special topics in nutrition

Given at the 2012 Alabama Society of Physician Assistants CME Conference

1. Special Topics in Nutrition Kristopher R. Maday, MS, PA-C, CNSC Surgical Physician Assistant Program Department of Nutritional Sciences University of Alabama at Birmingham

2. Topics to Be Discussed Medical Nutrition Therapy (MNT) management for: Diabetes Mellitus Kidney Disease Liver Disease Pancreatitis Critical Illness

3. Medical Nutrition Therapy Therapeutic approach to treating medical conditions and their associated symptoms using highly individualized, tailored diets devised and monitored by medical nutrition specialists and/or registered dieticians Often implemented before, or concurrently with, pharmacotherapy Can delay, halt, and even reverse the progression of certain diseases

4. Diabetes Mellitus American Association of Clinical Endocrinologists (AACE) 2011 Guidelines for initiation of MNT Any patient with “pre-diabetes” should be started on lifestyle modifications Fasting plasma glucose of 100-125 mg/ dL 2-hour post- prandial OGTT glucose of 140-199 mg/ dL Hemoglobin A 1C of 5.5-6.4% Endocrine Practice . 2011;17(supplement 2)

5. Diabetes Mellitus Goals of Medical Nutrition Therapy Attain and maintain optimal metabolic outcomes Blood glucose levels within normal range 2011 - AACE Guidelines Hgb A 1C < 6.5% Lipid and lipoprotein profile that reduces macrovascular complications 2004 - NCEP ATP-III Guidelines LDL < 100 mg/ dL HDL > 40 mg/ dL Blood pressure levels that reduce risk of vascular complications 2003 - JNC 7 Systolic < 130 mmHg Diastolic < 80 mmHg Prevent, or at least slow, the rate of development of chronic complications Aid in weight loss 5-7% weight reduction Clinical Diabetes . 2002;20(2)

6. Diabetes Mellitus Energy Balance One of the most important aspects of nutritional management in diabetes is weight loss Decreased insulin resistance, improved measures in glycemia and dyslipidemias , and reduction in blood pressures Goal is for a reduction of 5-7% of starting weight Balance between reduction of caloric intake and energy expenditures 500-1000 kcal deficit per day for healthy weight loss 150 minutes per week of moderate exercise Pharmacotherapy reserved for patients with BMI > 27.0 Bariatric surgery reserved for patients with BMI > 35 Clinical Diabetes . 2002;20(2)

7. Diabetes Mellitus Carbohydrates 45-55% of daily calories 150-300g per day Not all are created equal Sugars Glucose, fructose, sucrose, lactose Starches Amylose , amylopectin , resistant starch Fiber 14g per 1000kcal Total amount of carbohydrates is more important than the source or type Carbohydrate counting Low glycemic index carbohydrates may help with glucose control

8. Diabetes Mellitus Carbohydrate Counting Determine total daily allowance of carbohydrates Divide equally into meals and snacks “Net” Carbs Total carbohydrates from label or weighing If fiber > 5g, substract ½ of amount of fiber Substract ½ sugar alcohols Wisconsin Diabetes Essential Care Guidelines, 2011 Diabetes Care . 2003;26(8)

9. Diabetes Mellitus Lipids Diabetes Mellitus = Cardiovascular Disease Primary goal is to limit saturated fat and cholesterol <7% of daily calories for fat and < 200 mg/day for cholesterol Animal meats, butter, cream, cheese, hydrogenated oils, lard Sodium Dietary Approaches to Stop Hypertension (DASH) Diet Limit sodium to 2400mg/day and gradually lower to a goal of 1500mg/day

10. Chronic Kidney Disease Medical Nutritional Therapy is difficult 20-70% of dialysis patients suffer from primary protein-calorie malnutrition Anorexia from uremia, dysguesia , unpalatable diets, concurrent illnesses, act of dialysis 50% of new ESRD patients are caused by diabetes Kidney is a major site of insulin degradation As renal function declines, insulin levels rise Management changes throughout the spectrum of the disease process Kidney Disease Outcomes Quality Initiative, 2000

11. Chronic Kidney Disease Protein is most important factor in nutritional management Limiting vs Replacing Medical Nutritional Therapy Goals Maintain, improve, and, if possible, restore normal body composition of somatic proteins and visceral proteins Prevent or ameliorate uremic toxicity and other metabolic disturbances A.S.P.E.N. Nutritional Support Practice Manual. 2nd ed.

12. Chronic Kidney Disease 2000 – Kidney Disease Outcomes Quality Initiative (KDOQI) Guidelines Staging 1-5 based on progressively decreasing GFR Dialysis initiated in stage 4 3 main nutritional stratifications for renal disease No dialysis Intermittant (maintenance) dialysis Continuous dialysis Kidney Disease Outcomes Quality Initiative, 2000

13. Chronic Kidney Disease No dialysis Stage 1-3 Energy expenditure is similar to equal age healthy patients 35 kcal/kg/day Limit protein intake to 0.6-0.75 g/kg/d Decreases nitrogenous wastes and inorganic compounds Reduces incidence of hyperphosphatemia , uremia, hyperkalemia , metabolic acidosis A.S.P.E.N. Nutritional Support Practice Manual. 2nd ed.

14. Chronic Kidney Disease Intermittent (maintenance) hemodialysis Stage 4-5 Energy expenditure of 35 g/kg/d has been shown to maintain both neutral nitrogen balance and unchanging body composition Increased protein requirements due to removal of amino acids, proteins, and macronutrients 1.2 g/kg/day A.S.P.E.N. Nutritional Support Practice Manual. 2nd ed.

15. Chronic Kidney Disease Continuous hemodialysis 2 types Peritoneal Energy requirement is 35 kcal/kg/d Protein requirement is 1.3 g/kg/d CRRT Energy requirement is 35 kcal/kg/d Protein requirement is 1.5-2.5 g/kg/d A.S.P.E.N. Nutritional Support Practice Manual. 2nd ed.

16. Chronic Kidney Disease Diet recommendations Fluid restriction Electrolyte restriction Sodium, potassium, phosphorus, magnesium Determine protein needs Provide adequate calories to meet demand

17. Chronic Liver Disease Protein-calorie malnutrition is very prevalent in the cirrhotic population Pro-inflammatory cytokines suppress appetite Early satiety from gastric compression due to ascites Dysguesia and nausea from toxic metabolites Accelerated starvation Fat is preferred fuel source, so protein is broken down for gluconeogenesis and other biochemical pathways Malabsorption Bile salt deficiency and protein losing enteropathy Protein loss from paracentesis Poor diet A.S.P.E.N. Nutritional Support Practice Manual. 2nd ed.

18. Chronic Liver Disease Goals of Medical Nutrition Therapy Prevent protein-calorie malnutrition by slowing or stopping catabolism Attain optimal glucose control Correct and prevent vitamin and mineral deficiencies Improve hepatic function and promote regeneration by: Reversal of encephalopathy Reduction of ascites and edema Correction of electrolyte abnormalities Prepare for transplantation if necessary A.S.P.E.N. Nutritional Support Practice Manual. 2nd ed.

19. Chronic Liver Disease Energy requirements 25-35 kcal/kg/d 120% if patient is cachectic Add 10% if patient has ascites Protein requirements 0.5-0.7 g/kg/d and increase to 1.5g/kg/d if tolerated Ideally, protein should be high in branched chain amino acids and low in aromatic amino acids Fluid restrictions 1000-1500 ml/day Limit sodium to 2ooomg/day Fat soluble vitamin replacement A.S.P.E.N. Nutritional Support Practice Manual. 2nd ed.

20. Pancreatitis Mild disease can be managed with pancreatic rest, IVF, and analgesia with a rapid return to PO intake 20% of pancreatitis cases are severe Mean length of stay in hospital is 1 month Up to 30% mortality Factors contributing to malnutrition Increased energy requirement due to physiologic stress Reduced PO intake due to abdominal pain, nausea, paralytic ileus Increased nutrient loss from malabsorption Poor diet and physiologic reserve A.S.P.E.N. Nutritional Support Practice Manual. 2nd ed.

21. Pancreatitis Mainstay of treatment was NPO, NGT, and TPN Pancreatic rest vs Bowel rest 30-50% incidence of infection with severe pancreatitis Increased incidence of bacterial translocation with bowel rest Factors that effect pancreatic stimulation Neural Vagus nerve Chemical Protein, lipid, carbohydrate, gastric acid Mechanical Distention of the gastric wall and duodenum Hormonal Gastrin , secretin , VIP, CCK McClave SA . J Parenter Enteral Nutr . 2006;30(2)

22. Pancreatitis Key points in management Identify the severity of pancreatitis APACHE II or Ranson criteria <9 or <2 will likely not need nutritional support Duration of ileus Enteral nutrition is tolerated by > 50% of patients if ileus is <5 days in duration Obtaining enteral access Must be placed at or below the Ligament of Treitz Traditionally used fluoroscopy or endoscopy Newer beside modalities available Using a peptide-based or elemental tube feed will decrease the physiologic stress to breakdown the formula A.S.P.E.N. Nutritional Support Practice Manual. 2nd ed.

23. Enteral vs Parenteral Nutrition in Acute Pancreatitis McClave SA. J Parenter Enteral Nutr . 2006;30(2)

24. Critical Illness Malnutrition incidence as high as 40% in ICU Actual vs Perceived Benefits of providing adequat e nutrition during critical illness Supports anabolism and prevent catabolism Maintain a positive nitrogen balance Maintain immune system Decrease LOS, decreased ventilator days, and decreased overall mortality Woo. Nutr Clin Pract . 2010;25(2)

25. Critical Illness Metabolic Response to Critical Illness Hypermetabolism Increased energy demands Protein catabolism exceeds rate of protein synthesis Increased proteolysis for amino acids used in gluconeogenesis Hyperglycemia Insulin resistance from stress and increased gluconeogenesis from counter regulatory hormones Reduction in energy stores Increased lipolysis for glycerol and free fatty acids A.S.P.E.N. Nutritional Support Practice Manual. 2nd ed.

26. Long CL . J Parenter Enteral Nutr . 1979;3(6)

27. Critical Illness Goals of Medical Nutrition Therapy Provide adequate calories to prevent catabolism Over- and underfeeding can have adverse effects Calculations 25-30 kcal/kg/d Harris Benedict with appropriate stress factors Ireton-Jones Measurements Indirect Calorimetry Provide enough protein to keep in positive nitrogen balance 1.5 g/kg/d for most 2 g/kg/d for severe stress, trauma, burns 24hr urine urea nitrogen collection for direct measurement Early initiation of nutrition (within 48 hours) Enteral > Parenteral route A.S.P.E.N. Nutritional Support Practice Manual. 2nd ed.

28. Recap of Medical Nutrition Therapy Diabetes Mellitus Carb counting, weight loss, lipid reduction Chronic Kidney Disease Decrease protein early, increase protein late Fluid and electrolyte restriction Chronic Liver Disease Prevent PCM my providing adequate calories and low aromatic proteins high in BCAA

29. Recap of Medical Nutrition Therapy Pancreatitis Enteral=Good, TPN=Bad Must be trans- jejunal Elemental formula better Critical Illness Provide adequate energy to meet physiologic demands Provide adequate protein to maintain positive nitrogen balance Early initiation of enteral nutrition better than TPN

30. Questions Kristopher R. Maday, MS, PA-C, CNSC Assistant Professor University of Alabama at Birmingham Surgical Physician Assistant Program 1530 3rd Ave South, SHPB 466 Birmingham, AL 35294-1212 Telephone: [phone] [email protected]