Inflammatory bowel disease(IBD)-ulcerative colitis and Crohn

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Inflammatory bowel disease(IBD)-ulcerative
colitis and Crohns alterations in microbiome
play a role in IBD 1)different oxidative pathways
in the altered microbiome 2)more aggressive
nutrient uptake by altered microbiome-this
favours the altered microbiome 3) altered
microbiome is more virulent
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Exam 180 minutes 120 multiple choice
questions-120 points -4 short answer
question-60 points multiple choice-lecture
7a-12c inclusive short answer-whole Nutr2105
course
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Note Nutrition 2106-Fall 2014- Principles of
Nutrition in Metabolism Nutrition
2101-Nutritional Assessment-Theory-Fall
2014 Nutrition 2107- Introduction to Sports
Nutrition-Winter 2015
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Note Nova Scotia now spends 47 cents of every
budget dollar on healthcare(10 years ago it was
40 cents) -is the publically funded healthcare
system in its present form sustainable?
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Note Email sent today to first year and senior
students. Email is regarding completion of NSEE
survey (first year and senior students) .
Please complete to help CBU better help you!
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Lecture 10a 17 March 2014   Enteral and
Parenteral Feeding
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Enteral Feeding   -refers to use of intestine
(uses oral or tube feeding to direct nutrients to
intestine)   -called complete enteral feeding if
formula is primary source of nutrients   -complete
formulas can be used in smaller quantities to
supplement table foods   -complete formulas
required if patient is on tube feeding or oral
liquid diet for more than a few days
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Types of enteral formulations -standardised
-hydrolysed -modular -characterised by
type of protein in the formulation
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Types of enteral formulations Standardised   Appro
priate for people who are able to digest and
absorb   Contain complete proteins (complete
refers to whole proteins or combination of
protein isolates(purified proteins))   Blenderised
formulas contain protein from pureed foods (e.g.
blenderised meats)
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• Types of enteral formulations
• Hydrolysed
•  
• Pre-digested protein- so only get small
  peptides or just free amino acids
•  
• Some have medium chain triglycerides or are
  very low in fat

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Types of enteral formulation Modular   Provide a
single nutrient   Modules can be combined with
other modules or with minerals and/or vitamins to
address the specific needs of a patient
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• Candidates for tube feeding
• Anybody who
• can not get food down orally or
• has mental incapacitation
• are malnourished or
• has high nutrient requirements or extensive
  intestinal resections or is on a ventilator
• gastrointestinal obstructions or fistulas
• in short anyone who cannot access or utilise GI
• tract on their own

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• Distinguishing characteristics of enteral
  formulations
•  
• Nutrient density
• 1.0  kcal/ml- standard
• 1.2 2.0 kcal/ml for nutrient dense formulas
  -nutrient dense formulations are given in
  smaller volumes to persons with fluid
• balance issue- e.g. congestive heart
  patients

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Distinguishing characteristics of enteral
formulations 2) Fibre   if administered over
short time - low to moderate fibre - otherwise
gas and distension can be an issue   if long term
administration -then higher amounts of fibre
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Distinguishing characteristics of enteral
formulations 3) Osmolality- measure of
concentration of molecular and ionic particles in
solution -serum is 300 milliosmoles/kg of
solution -isotonic solution is 300
milliosmoles/kg -hypertonic is greater
than 300 milliosmoles/kg of solution
-hypertonic can induce diarrhea in intestine so
a slow introduction of hypertonic solution for
intestinal route is essential  
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Tube placement-1) transnasal or 2) direct
catheter  1)Transnasal Nasogastric-children and
adults-larger nose than infants so nasogastric
is used in children and adults Orogastric-infa
nts- smaller nose than adults and children so
orogastric is used   Nasoduodenal-nose to
duodenum   Nasojejunal placement-nose to
jejunum  
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Tube placement 2) Catheter direct to stomach or
jejunum Enterostomies- surgical placement of
catheter   -Gastrostomy- direct to
stomach   -Jejunostomy-direct to jejunum
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Safehandling of formulations   Open and closed
systems   Open- exposed to air   Closed-not
exposed to air   Keep your fingers out of the
soup for open systems
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• Initiating and progressing a tube feeding
•  
• Formula delivery techniques-Intermittent feeding
•  
• Best to stomach
• No more than 250-400 ml over 30 minutes
• Use- depends on tolerance
•  
• Bolus feeding included here (300-400 ml) in 10
  minutes
•  

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Initiating and progressing a tube feeding  
Formula delivery techniques Continuous
feeding Delivered slowly over 8-24
hours   Good for people who have received
nothing though GI tract for a long time,
hypermetabolising persons and those
receiving intestinal feedings   Formula
volume and strength institutionally based-
standard operating procedures (sops)  
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Initiating and progressing a tube feeding  
Additional matters Supplemental
water -standard formulas contain about 850
ml of water/per formula -most people need
about 2 L of water per day   Gastric
residual volume -amount left over from
previous feedings-significance of this?
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2 Youtubes- enteral feeding https//www.youtube.c
om/watch?vEWtqxJeyCMA   https//www.youtube.com/w
atch?vhploKHe-V4U
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Class activity Design an enteral feeding for the
pathology/problem of your choice that meets the
dietary principles of adequacy, variety,
moderation, nutrient density, energy control, and
balance
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Lecture 10b 17 March 2014   Parenteral Feeding
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Parenteral Feeding (going around ie circumventing
the intestine) Nutrients go directly into blood
stream bypassing gastrointestinal tract-this is
done by intravenous needle or catheter Used when
a patient cannot, due to physical or
psychological impairment, consume sufficient
nutrients enterally   Used when patients gi
system will not adequately process food for
body   Actual infusion depends on site of
infusion and patients fluid and nutrient
requirements
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Types of Parenteral Nutrition   Peripheral
parenteral nutrition (PPN)- peripheral vein
used   Total parenteral nutrition (TPN)-superior
vena cava used   Basic difference between the
two is the concentration of nutrients infused
(higher concentration is used for TPN due to
more rapid dilution in superior vena cava)  
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Parenteral Feeding Usual fluid volume is 1.5-2.5
L over a 24 hour period for most people  
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Parenteral Feeding Composition of ingredients in
bag for intravenous delivery Dextrose Amino
acids Lipid emulsion Sterile water Electrolytes
Vitamins
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Carbohydrate   Dextrose- provides 3.4 kcal/g and
not 4 kcal/g -difference is due to
what?   Concentration is 12.5 (max for
peripheral introduction) to 25 (total
parenteral nutrition)   Restricted in
ventilator patients because oxidation of glucose
produces more carbon dioxide than does oxidation
of fat
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Protein   Mixture of essential and non-essential
amino acids   Concentration 3.5-15
  Quantity of amino acids depends on patients
estimated requirements and hepatic and renal
function-why?
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Lipid emulsions   Safflower and soybean oil
with egg lecithin used as an emulsifier (why
the emulsifier and how does it
work?)   Isotonic   Significant source of
calories
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Lipid emulsions Available in 10, 20, 30
concentrations supplying 0.9 and 1.8 and 2.7
kcal/ml respectively-Do the math   Usual dose
is 0.5 to 1 g/kg/day to supply 20-30 of total
kcal requirement   IV fat contradicted for
severe hepatic pathology, hyperlipidemia or
severe egg allergies   Used cautiously with
atherosclerosis, blood coagulation disorders
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Electrolytes   Dictated by patients blood
chemistry values and physical assessment
findings  
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Standard multivitamin and trace mineral
preparations added to parenteral solutions to
meet micronutrient needs  
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PPN -must be isotonic and therefore low in
dextrose and amino acids to prevent phlebitis
and increased risk of thrombus
formation   -need to maintain isotonic solutions
of dextrose and amino acids while avoiding
fluid overload limits the caloric and
nutritional value of PPN  
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PPN   delivers complete but limited
nutrition   the final concentration cannot exceed
12.5 dextrose-also uses lower concentrations of
amino acids   vitamins and minerals are
added   lipid emulsion may be added to supplement
calories depending on the patients tolerance
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PPN -provides temporary nutritional
support   -short term- 7-10 days and do not
require more than 2000 to 2500 kcal per day
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PPN -may be used for a post surgical ileus or
anastomotic leak or for patients who require
nutritional support but are unable to use TPN
because of limited accessibility to a central
vein   -sometimes used to supplement an oral diet
or tube feeding or transition from TPN to enteral
intake  
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TPN Hypertonic solutions provide more dextrose
and/or protein but they must be delivered
centrally in a large diameter vein so that they
can be quickly diluted  
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TPN   TPN is used when nutritional requirements
are high and anticipated need is relatively
long 3 litres of 10 dextrose provides only 1020
kcal -calculation    
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TPN -traditionally-catheter to superior
vena cava figure 21-2    
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TPN Indications severe malnutrition GI
abnormalities due to obstruction, peritonitis,
severe acute pancreatitis after surgery or
trauma especially that involving extensive burns,
sepsis need for supplementation of inadequate
oral uptake in patients who are being treated
aggressively for cancer bone marrow
transplantation
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TPN cyclic -constant infusion for 8-12
hours -used for home patients -used to
support inadequate oral intake -allows
insulin and glucose to drop when infusion is
not taking place   -switch from continuous TPN
to cyclic TPN should be gradually decreased by
several hours per day and signs of glucose
overload and fluid imbalance should be
monitored
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Note
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Lecture 10c 17 March 2014 Surgery and Burns
 
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Surgery   -patient should be well nourished
prior to surgery-this gives better recovery  
-however, surgical patients are
often malnourished due to anorexia,
nausea, vomiting, burns, fever,
malabsorption, and blood loss  
-surgical prep- range of actions include
-high calorie protein diet
-enteral feeding
-parenteral feeding
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Surgery -nothing by mouth (NPO) for a
least 8 hours prior to general anesthesia due
to risk of aspiration   -oral intake
is resumed after bowel sounds return- usually
24-48 hours after surgery   -start with clear
liquids to full liquids to soft or regular diet
as tolerated post-op   -usually a high protein
high calorie diet is appropriate-this helps with
healing
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Burns   -hypermetabolism involved-
why?    -large quantities of nutrients leech
through burn area   -therefore fluid and
electrolyte imbalances are a problem
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Burns -result in anorexia, pain,
emotional trauma, weight loss and immune
incompetence, malnutrition    
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Burns -after fluid and electrolytes are
addressed and by hour 72 (if bowel sounds)- oral
intake begins   -if no bowel sounds by hour 96
then PPN or TPN
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Burns - regardless of routes of
administration   -Protein 1.5-3.0 g /kg body
weight/day 20-25 protein, 50
carbohydrate, 25 fat -Kcal- additional
40-60 kcal/kg body weight/day   -high fluid
intake including more potassium, zinc and
vitamins A and C (zinc, vitamins A and C for
wound healing) and vitamins B1, B2 and B3 (in
proportion to increased energy intake)
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Table 29-1, p. 870
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Table 29-2, p. 903
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Table 29-3, p. 904
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Cancer Dietary factors - cancer initiators -
these dietary components start cancer   -addit
ives and pesticides are of particular but not
exclusive concern here   -stomach cancer
particularly high in parts of world where pickled
or salt-cured foods that produce carcinogenic
nitrosamines are consumed
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Cancer Dietary factors -alcohol associated with
high incidence of some cancers, especially of the
mouth, esophagus and liver in all persons and
breast cancer(post- menopausal) in
females -beer and scotch may contain
nitrosamines -wine and brandy may contain
urethane -urethane and nitrosamines are
carcinogens -moderation is the key to prevention
here
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Dietary factors cancer promoters and
inhibitors -cancer promoters
accelerate the rate of progression of cancer
once it has started   - eg excess dietary
fats -linoleic acid- has been
suggested to promote   -omega 3s
have been suggested to prevent or delay
cancer development
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Dietary factors-antipromoters   Fruits and
veggies as per Canadas food guide -fibre speeds
up gi transit time thus reducing carcinogen
exposure   -fruits and vegetables containing
antioxidants that scavenge free radicals such
free radicals contribute to cancer   -various
phytochemicals activate enzymes that can destroy
carcinogens
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Once cancer starts   -do nutritional assessment
and respond accordingly   -early dietary
intervention prepares body for stresses that
lay ahead  
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AIDS   Weight loss, diarrhea, seborrhea, eczema,
fever, sweating-nutritional implications? Nutrit
ional implications can further deteriorate
patients health e.g. further immune response
compromise Kcal requirement is increased
compared to non-infected persons in good
health Protein requirements 1-2 g/kg bw/day due
to lean body mass loss and other protein losses
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AIDS   Drugs can exacerbate nutritional
difficulties (table)
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AIDS Fat medium chain triglycerides(mct)
(6-12 carbon fatty acids) for additional
calories -lipase and bile not required for mct-
therefore easier absorption
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AIDS Vitamins and Minerals recommendation-close
to DRI-otherwise adverse interactions with
antiretroviral drugs
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AIDS Feedings -small, numerous
meals -liquid commercial preparations -antidia
rrheals shortly before meals -high soluble
fibre foods like oatmeal, cooked carrots,
bananas, peeled apples and apple sauce may help
slow transit time (diarrhea reduced perhaps)