Optimizing Nutrition
Therapy
Prevalence of Malnutrition
Malnutrition occurs frequently in hospitalized patients.
It is associated with:
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Increased complications
Prolonged length of stay
Higher hospital costs
Increased mortality
Nutritional Screening and Assessment
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Screening identifies and classifies patients at risk for
malnutrition
Assessment – evaluates nutritional status
– biochemical parameters
– anthropometric measurements
– Subjective Global Assessment (SGA)
Early Detection of Malnutrition
Patients at risk:
History of chronic diseases
Psychiatric disorders
Gastrointestinal diseases
Chronic renal insufficiency
Impaired immune function
Cancer
Diabetes
Elderly
Chronic renal failure
COPD
Normal Energy Metabolism and
Nutritional Needs
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Nutrients are necessary to sustain life
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Energy requirements vary according to clinical condition
The utilization of nutrients depends on availability
(fasting) and the inflammatory response (stress)
Caloric distribution varies according to metabolic status
Metabolic Response to Starvation and
Trauma: Nutritional Requirements
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The metabolic response to starvation is an adaptive
mechanism
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Nutritional needs increase in trauma
Nutritional Requirements
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Energy
– Harris-Benedict Equation x stress factor
– “Rule of thumb”: 25 – 30 kcal/kg BW
– Indirect calorimetry
Protein
– Stable patients: 0.8 – 1.0 g/kg BW
– Stressed patients: 1.2 – 2.0 g/kg BW
Nutritional Requirements
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Lipids
– Stable patient:
– Stressed patient:
25% – 30% of calories
20% – 35% of calories
Carbohydrates
– Stable patient:
50% – 65% of calories
Diabetes mellitus, hyperglycemia, COPD, hypercapnia,
may benefit from
–  carbohydrates (about 30% of calories)
–  lipids (about 50% of calories)
Nutritional Requirements
• Vitamins and Minerals
– Stable patient:
– Stressed patient:
(COPD, cancer,
critical care)
– Hepatic patient:
100% daily recommended intake
100% daily recommended intake,
antioxidants
– Renal failure:
Na, K, CI, PO4,
Vitamin A
antioxidants,
Vitamins B6, B12
– HIV/AIDS:
BCAA, B Vitamins,  folate
Na, Cu, Fe, Mn
Early Intervention
as Part of Initial Care
Enteral Nutrition
• Oral supplements
• Tube feeding
Parenteral Nutrition
• Total
• Peripheral
“If the gut works, use it!”
Parenteral Nutrition
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Supplies partial or total nutrition through venous access
Supplies practically all essential nutrients
Metabolic monitoring and changes in solution
components are needed to
maintain metabolic balance
Benefits of Enteral Nutrition Therapy
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Maintains GI tract structure and function
Enhances intestinal immune function
Reduces bacterial translocation
Decreases risk of sepsis
Fewer complications than with parenteral
nutrition
Lower costs
Improved Patient Outcomes
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Improved wound healing
Decreased risk of complications
– Nosocomial infection
Decreased length of stay
Decreased healthcare costs
Barriers to Nutritional Intervention
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Lack of physician awareness
Limited physician knowledge of nutrition therapy
Minimal support from administration
Lack of Physician Awareness
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Physicians consider this the responsibility of other
professionals
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Nutritional assessment not included by physician as
part of the initial history and physical
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Only considered important when severe malnutrition is
evident
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Nutritional evaluation could be included in patient
history and physical exam with minimal effort
Lack of Administrator’s Awareness
Administrator’s lack the knowledge of the
positive impact that nutrition therapy can have
on patient care and in reducing hospital costs.
Goals of the TNT Program
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Improve patient care
Give physicians the knowledge to prevent and
manage nutrition-related problems. Teach them how to
do this early, safely and efficiently.
TNT Program: Next Steps
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Screening
– Establish a nutritional screening and
assessment program
Standards
– Develop guidelines and standards of care for
nutrition therapy
Intervention
– Promote early nutrition therapy
TNT Program: Next Steps
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Education
– Raise awareness and increase knowledge of
healthcare team members on importance of
nutrition therapy
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Research
– Collect data on the incidence of malnutrition and
positive clinical outcomes of nutritional intervention
CONGRATULATIONS!
TNT was sponsored by Abbott Laboratories