Transcript Food Fortification: Benefits and Possible Risks

Clinical Nutrition
Prof. Albert Flynn
University College Cork
Nutrition activities in hospitals
• Basic care
• Diagnosis
• Therapy
• Teaching/education (students, staff, patients)
• Research
Basic care
•
Who is responsible for feeding patients?
•
Is food intake monitored?
•
Is body weight monitored?
•
Does dietician see every patient?
Diagnosis (Nutritional status)
Anthropometry:
•
height, weight, skinfold, weight history
Clinical
•
evidence of nutritional status
– hair, skin, nails, eyes, perioral, oral, glands
– heart, liver, muscles, bones, neurological etc.
Diagnosis (Nutritional status)
Biochemical
• Serum Albumin
• Haemoglobin
• Ferritin
• Haematocrit
• Folate
• Phosphate
• Calcium
• Sodium
Dietary assessment
• recall of food intake - diet history
Nutrition therapy
•
Doctor:
•
Dietician: diet formulation and menu plan,
patient counselling
recommends diet
•
Doctor - dietician interaction
•
in-patient vs out-patient
•
Need for community dieticians!
Does malnutrition occur in the
hospitalised patient?
•
•
•
malnutrition may be a cause and/or an
effect of illness
malnutrition may be present on admission
malnutrition may occur during hospital stay
Does malnutrition occur in the
hospitalised patient?
Weinsier et al. (1979) Am. J. Clin. Nutr. 32, 418.
Hospital malnutrition. A prospective evaluation of
general medical patients during the course of
hospitalization.
• randomly selected group of patients (n 134)
• nutritional status assessed at entry & after ≥2
weeks
Does malnutrition occur in the
hospitalised patient?
On admission 48% of patients had a high likelihood of
malnutrition, which correlated with
- a longer hospital stay (20 vs 12 d for patients with a
low likelihood of malnutrition)
- increased mortality rate (13 vs 4%)
Does malnutrition occur in the
hospitalised patient?
Likelihood of malnutrition increased with
hospitalization in 69% of patients
index
reduced arm circumference
reduced weight
reduced haematocrit
reduced albumin
% affected
79
74
64
47
• Nutritional status worse at discharge than at
admission
• causes? Can it be avoided?
Undesirable practices identified (Weinsier1979)
• failure to record Ht, Wt, Wt. history
• failure to record diet history, food intake
• incomplete use of biochemical tests
• prolonged use of glucose/saline I.V. feeds
• withdrawing meals - diagnostic tests
• failure to recognise increased nutrient needs
• poor doctor-dietician interaction
• failure to monitor effects of medication/therapy on
appetite/food intake
• lack of nutrition awareness/education in doctors
Early nutrition assessment pays off
•Kruizenga HM. et al. 2005 Effectiveness and costeffectiveness of early screening and treatment of malnourished
patients. Am J Clin Nutr. Nov;82(5):1082-9.
• 588 patients in mixed surgical-medical wards given either
routine care (including whatever nutritional element may have
been provided)
or
• were screened on admission using the Short Nutritional
Assessment Questionnaire and those who were found to be
malnourished were given protein-energy supplements (600
kcal and 12 gm protein/day)
Early nutrition assessment pays off
• Results: Recognition of malnutrition increased from 50% to
80% in the intervention group
• Malnourished patients spent less time in hospital in
intervention than in the control group (11.5 vs 14.1 days,
p<0.05)
• estimated additional cost for nutritional screening and
treatment of €76 for each hospital day saved
Nutritional treatment of disease
• Dietary modification
– qualitative
– quantitative
– communication
– behaviour modification
– motivation
– patient education
Nutritional treatment of disease
• Under-nutrition - protein, energy, vitamins, minerals
• Over-nutrition (obesity) - energy restriction
• digestive disorders
– cystic fibrosis
– colitis
– coeliac disease
• Metabolic disorders - diabetes mellitus
• diseases of liver, kidney, cardiovascular
• injury, surgery, convalescence
• enteral/parenteral nutrition
Therapeutic diets - cystic fibrosis
1. antimicrobials
2. physiotherapy
3. diet
• high energy (120-150% RDA)
• no fat restriction
• supplement with energy drinks
• pancreatic enzyme replacement
• supplement with vitamins (A, D, E)
• Growth failure
• overnight nasogastric feeding
Diabetes mellitus
European Association for the Study of Diabetes [EASD]
1999
Overall aims:
• to help optimize glycaemic control and reduce risk factors for
cardiovascular disease and nephropathy
Diabetes mellitus
• those overweight
– reduce weight [BMI 18.5-25 kg/m2 for adults] and
prevent wt. gain
• moderate physical activity at least 20-30 minutes
most days
– improves glucose tolerance, blood lipid profile, weight
control and maintains muscle mass
Diabetes mellitus
• Saturated and trans-fatty acids under 8-10% of total energy
– Replace with polyunsaturated fat
• Total fat intake should not exceed 35% energy intake
• adequate intake of n-3 fatty acids
– oily fish and plant oils (e.g. rapeseed oil, soyabean oil)
• Protein intake 10-20% total energy
– In nephropathy - protein intake lower (0.8g/kg body weight/day)
Diabetes mellitus
• Carbohydrate + monounsaturated fatty acids to provide 6070% of energy intake.
• Carbohydrate-containing foods rich in dietary fibre or with low
glycaemic index
– vegetables, fruits and cereals
• Moderate intakes of sucrose <10% E
• Insulin-treated patients
– timing and dose of insulin to match with the amount and time of
carbohydrate-containing food intake
– to avoid both hypoglycaemia and excessive postprandial
hyperglycaemia
Diabetes mellitus
• 5 or more servings of vegetables & fruit
• restrict salt intake to < 6g/day.
• alcohol
– intakes of up to 15g for women and 30g for men are acceptable
– for those on insulin alcohol with a meal including carbohydratecontaining foods - risk of hypoglycaemia
• compliance with dietary recommendations??
Effect of Phytosterols on Plasma Cholesterol
• Phytosterols containing foods (e.g. fat spreads)
consumed in typical dietary amounts lower LDL
cholesterol by 10-15%
• sterols have additive effects with statins
Phytosterols and Plasma Cholesterol - mechanism
• inhibit cholesterol absorption
• cholesterol forms crystals and is excreted in faeces
• also reduces cholesterol reabsorption from biliary cholesterol
• while liver increases cholesterol synthesis and LDL receptors
in response to this, it is not sufficient to counteract the
reduction in cholesterol absorption so blood cholesterol falls