Advanced Nutrition

What are the malabsorption syndromes?

• Crohn’s disease

• Pancreatic insufficiency

• Bariatric surgery – particularly Roux-en-Y, Duodenal switch

• Post GI resection for cancer or obstruction

What are medically diagnosed deficiencies?

• Iron

• low ferritin (even in the absence of low HB)

• Osteoporosis (Calcium and vitamin D)

• Folic acid in chemotherapy

• Increased requirements

• Post trauma, inflammation, alcohol abuse

Why nutrition and dietary counselling  plays a part in GI conditions?

• Eating and drinking stimulates the gastro-colic reflex

• intestines have a nerve supply so sense pain

• Food produces waste products, wind, gas

• don’t absorb fuels the bacteria in our large bowel

• Any area affected by disease, surgery and / or strictures may affect tolerance to certain foods and symptoms, dietary advice counters the effect of maldigestion and malabsorption

Describe IBS?

• Affects 10-20% of the general population

• Chronic, relapsing and often life-long disorder

• Twice as common in women as in men

• Affects 40% of patients with IBD

What test would you do for IDB?

check faecal calprotectin / CRP / FBC/colonoscopy/capsule endoscopy

What test would you do for Bowel test?

qFIT test / colonoscopy

What test would you do for lactose intolerance?

breath test or exclusion and challenge

What test would you do for Coeliac disease?

screen using TTG-IgA/ gluten sensitivity

What test would you do for Bile acid malabsorption?

SeHCAT scan – low fat diet and bile sequestrants

What test would you do for Dysbiosis / Small intestinal bacterial overgrowth (SIBO)?

glucose/lactulose breath test

Describe lactose intolerance?

deficiency of lactase enzyme
Can arise after insult or injury to bowel as lactase produced on tips of villi

Small amounts can be tolerated e.g. milk in tea

5% Caucasians, up to 85 % of Hispanics, Asian ethnicity
Medications contain lactose

What doe dietary advice in IBD depend on?

• Whether disease is active

• Previous surgery / stoma / presence of strictures

• Symptoms, area of the bowel / gut affected

• Stool frequency / type

• Types of food preferred, fibre intake, meal patterns, life-style factors, routines

What needs to be regularly monitored in IBD?

Micronutrients

Which micronutrients need to be monitored in IBD

Anaemia & low ferritin < 30 mcg/l treat
Low vitamin D
B12 deficiency
Hypomagnesaemia / hypokalaemia
Sodium depletion – low urinary sodium

If patient is being treated with sulphasalazine / methotrexate what should they also get?

Vitamin B9/folic acid

Why does Vitamin B12 warrant special attention as a pharmacist?

when 30-60 cm terminal ileum affected or > 20 cm distal ileum resected

Why does Vitamin D warrant special attention as a pharmacist?

deficiency requires therapeutic doses

Why does iron warrant special attention as a pharmacist?

max absorption from gut = 18 mg/day ref: WHO

Why does Electrolytes warrant special attention as a pharmacist?

sodium, potassium) and zinc / magnesium supplements to replace high losses

When to consider enteral nutrition liquid diet?

• Limited ability to eat due to inflammation / pain / strictures

• Significant weight loss / nutritionally depleted

• Intolerant of immunomodulators / biological therapy / lack of response to medication

• Patient choice

What is the risk of diarrhoea and high output stomas?

Risk of dehydration

• Due to loss of significant amounts of fluid and electrolytes (Na, K)

• Hypotonic can further increase losses

What is the management risk of dehydration in diarrhoea and high output stomas?

St Mark’s solution: isotonic solution

What is the treatment for IBD in remission?

Normal healthy diet
Normal BMI
Add ons such as supplements and injections as required
FODMAP for some

What should happen pre op?

No prolonged fast pre op
pre-op carbohydrate drink
Treat malnutrition
Optimise metabolic control
Integrate nutrition and hydration into overall management

What should happen post op?

Re-establish oral feeding
Early mobilisation to facilitate protein synthesis and muscle function
counselling by a dietitian to manage stool / stoma output, optimise nutritional status short and long term

How should diet be adjusted in cancer?

to symptoms, treatment, phase & trajectory

What are the 9 underlying problems affecting nutritional status & enjoyment of food in GI conditions?

Food avoidance
Early satiety
Malabsorption
Physical issues
Bowel issues
Side effects meds
Social reasons
Surgery
Metabolic derangement

Examples of cancer that will affect nutrition

1. Oesophageal cancer

2. Head and neck

3. Pancreatic

4. Stomach / upper GI

5. Colorectal

What are the issues with head and neck cancer and nutrition?

impairment of swallowing at diagnosis, during treatment and after (scarring)
Malnutrition
Modified textures
supplementary nutrition or all nutrition via gastrostomy
All under care of dietion

What are the issues with Colorectal cancer and nutrition?

may have shortened bowel
radiation damage affecting reabsorption of water and electrolytes
High output stoma → isotonic

Lifestyle for risk factors obesity low fibre
Refer to dietitian

What are the consequences of malnutrition?

Unintentional weight loss
Loss of muscle mass
Psychology
Immunity
Hypothermia
Renal function
Wound healing
Liver
Breathing

What percentage of malnutrition is in community?

93%

How to treat malnutrition?

• Manage symptoms

• Improve nutritional intake

• Improve or maintain nutritional status

• Improve function (ADLs, grip strength)

• Improve clinical outcomes such as reduced complications, reduced mortality, reduced hospital readmission

• Reduce healthcare use and costs e.g. length of stay

• Be acceptable to the patient and carer

Define oral nutrition support?

fortifying food with protein, carbohydrate and/or fat plus minerals and vitamins;
Snacks
Meal patterns

Different types of ONS?

• Standard 1 – 1.5 kcal/ml

• High energy / nutrient dense

  • 2.4 kcal/ml

• Nutritionally complete

• Nutritionally incomplete

• High protein (NEW)

• Compact (NEW) 2.4 kcal/ml

• Peptide based / elemental

When is parenteral feeding for?

)Reserved for when the gut doesn’t work

How can pharmacists aid in nutrition management?

• Identifying patients through observation / conversations

• Check correct feed, flavours, type etc

• Advise on concurrent drug therapy / vitamins / minerals /IV fluids

• Check adherence and tolerance

• Facilitate continuity of supply of products in the community

• Audit practice