Today s Objectives. What does malnutrition look like? Malnutrition Often Is Recognized But Sometimes Is Not Addressed. Nutrition Screening

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Today s Objectives Recognize the role malnutrition plays in chronic and nonhealing

least three new nutrition strategies Nancy Collins, PhD, RDN, LD, FAPWCA, FAND

Nutrition is one of the important vital signs, just as blood pressure or pulse.

Association, and the National Council on Aging Photos courtesy of Dr M.

are malnourished 20% of the malnourished receive a consult 1 Dietitian recommendations

a screening for risk of malnutrition or existing malnutrition Use a validated tool:

(Kovacevich et al; 1997) Nutritional Risk Index (NRI) (Honda et al; 2016) Nutritional

1 Today s Objectives Recognize the role malnutrition plays in chronic and nonhealing wounds Identify the key nutrients needed to fuel the wound healing process Explain at least three new nutrition strategies Nancy Collins, PhD, RDN, LD, FAPWCA, FAND drnancycollins.com What does malnutrition look like? Nutrition is one of the important vital signs, just as blood pressure or pulse. Wellnourished people tend to have shorter hospital stays, fewer complications, and speedier wound healing after surgery. Joint statement of the American Academy of Family Physicians, the American Dietetic Association, and the National Council on Aging Photos courtesy of Dr M. Furtado Malnutrition Often Is Recognized But Sometimes Is Not Addressed 50% of patients are malnourished 20% of the malnourished receive a consult 1 Dietitian recommendations are implemented only 42% of the time 2 Nutrition Screening Every patient should receive a screening for risk of malnutrition or existing malnutrition Use a validated tool: Malnutrition Screening Tool (MST) (Wu et al; 2012) Nutrition Risk Classification (NRC) (Kovacevich et al; 1997) Nutritional Risk Index (NRI) (Honda et al; 2016) Nutritional Risk Screening 2002 (NRS2002) (Bauer et al; 2005) Short Nutrition Assessment Questionnaire (SNAQ) (Pilgrim et al; 2016) 1. Somanchi M et al. JPEN J Parenter Enteral Nutr. 2011;35(2): Skipper A et al. J Am Diet Assoc. 1994;94(1):4549.

Pick the Tool That Works Best for Your Population Bauer JM et al. Z Gerontol Geriatr. 2005; 38(5):322327. Kovacevich DS et al. Nutr Clin Pract. 1997;12(1):2025. Honda Y et al.

nutrition at every visit: Current education materials US Centers for Medicare & Medicaid Services. www.medicare.gov/coverage/nutritiontherapyservices.html. Medicare.gov website.

Malnutrition Defined Develops when the body does not get the right amount of the macronutrients, vitamins, minerals, and other nutrients it needs to maintain healthy tissues

excreting them more rapidly than it is possible to replace them EtiologyBased Malnutrition Definitions Farlex. http://medicaldictionary.thefreedictionary.com/malnutrition.

10 The Stress Response Amplified fightorflight reaction to injury, illness, or infection Hormonal response: Increased cortisol and catecholamines Decreased growth hormones,

2 Pick the Tool That Works Best for Your Population Bauer JM et al. Z Gerontol Geriatr. 2005; 38(5): Kovacevich DS et al. Nutr Clin Pract. 1997;12(1):2025. Honda Y et al. Am J Cardiol. 2016;118(4): Pilgrim AL et al. J Nutr Health Aging. 2016;20(1):37. Wu ML et al. J Gerontol Nurs. 2012;38(6):3845. I have identified patients at risk. Now what? Medicare and insurance benefit: Part B who meet at least one of these conditions: Have diabetes Have kidney disease Have had a kidney transplant in the last 36 months Discuss nutrition at every visit: Current education materials US Centers for Medicare & Medicaid Services. Medicare.gov website. Accessed February 20, Malnutrition Defined Develops when the body does not get the right amount of the macronutrients, vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ function Occurs in people who are either undernourished or overnourished Undernutrition is a consequence of consuming too few essential nutrients or using or excreting them more rapidly than it is possible to replace them EtiologyBased Malnutrition Definitions Farlex. Free Dictionary website. Accessed February 20, Adapted from Jensen GL et al. JPEN J Parenter Enteral Nutr. 2009;33(6): The Stress Response Amplified fightorflight reaction to injury, illness, or infection Hormonal response: Increased cortisol and catecholamines Decreased growth hormones, anabolic hormones, and testosterone Energy demands increase; rapidly depletes lean body mass (protein stores) Results in catabolism and hypermetabolism Prolonged Stress Response Results in Catabolism and Hypermetabolism Catabolic State A progressive loss of lean body mass in response to any significant insult, physiologic or psychologic Hypermetabolic State An increase in energy demands that accompanies any significant physiologic and/or psychologic insult Molnar JA. Nutrition and Wound Healing. Boca Raton, FL: CRC Press; 2007.

Relationship Between Loss of Lean Body Mass and Wound Healing Bed Rest, Age, and Hospitalization Increase Loss of Muscle Healthy Young 28 Days Inactivity 1 Healthy Elders 10 Days

5 1 lb loss of muscle 2.2 lb loss of muscle 2.2 lb loss of muscle 1. PaddonJones D et al. J Clin Endocrinol Metab. 2004;89(9):43514358. 2. Kortebein P et al. JAMA. 2007;297(16):17721774. 3.

Factors That Affect the Nonhealing Wound Protein Energy Malnutrition Loss of Lean Body Mass Nutrition Interventions Sustained Inflammation Objectives of Medical Nutrition Therapy Provision

mass General Guidelines for Calculation of Nutritional Requirements Calories Normal 2530 Existing/risk of malnutrition or pressure injury Protein kcal/kg/day 3035 RDA 0.

3 Relationship Between Loss of Lean Body Mass and Wound Healing Bed Rest, Age, and Hospitalization Increase Loss of Muscle Healthy Young 28 Days Inactivity 1 Healthy Elders 10 Days Inactivity 2 Elderly Inpatients 3 Days Hospitalization 3 LBM loss of >10% 0. Wound healing is impaired LBM loss of >20% Wound healing ceases 2.0 New wounds develop lb loss of muscle 2.2 lb loss of muscle 2.2 lb loss of muscle 1. PaddonJones D et al. J Clin Endocrinol Metab. 2004;89(9): Kortebein P et al. JAMA. 2007;297(16): PaddonJones D. Lean body mass loss with age. Columbus, OH: Abbott Nutrition; Factors That Affect the Nonhealing Wound Protein Energy Malnutrition Loss of Lean Body Mass Nutrition Interventions Sustained Inflammation Objectives of Medical Nutrition Therapy Provision of adequate nutritional substrate on a daily basis: Calories Protein Fluids Vitamins and minerals Adjunctive therapy (eg, amino acids) Goal: To maintain and/or restore weight and lean body mass General Guidelines for Calculation of Nutritional Requirements Calories Normal 2530 Existing/risk of malnutrition or pressure injury Protein kcal/kg/day 3035 RDA 0.8 g/kg/day Existing/risk of pressure injury Existing/risk of malnutrition Fluids 1mL/kcal National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Cambridge Media: Perth, Australia; 2014.

4 General rules means apply your clinical judgment! Wound drainage Patient wishes Type of bed Renal function Fever Comorbidities Nausea/vomiting Obesity Nutrients in Real Terms 125 lb (57 kg) female with Stage 3 pressure injury (PI) kcals/day (3035/kg) g protein/day ( g/kg): Real terms about 1012 oz of meat/day ml fluid/day: Real terms about 78 cups/day Normal Nutrient Partitioning Defective Nutrient Partitioning Proteins Carbohydrate Fat Proteins Carbohydrate Fat Protein Synthesis (Lean body mass) Energy Production (ATP) Energy Depot (Fat) Protein Synthesis (Lean body mass) Energy Production (ATP) Energy Depot (Fat) 25% to 30% of the amino acids are misused Daily Protein Distribution: Typical Daily Protein Distribution: Proposed Maximum rate of protein synthesis Maximum rate of protein synthesis Catabolism Anabolism 10 g 15 g 65 g Breakfast Lunch Dinner A skewed daily protein distribution fails to maximize potential for muscle growth Total protein 90 g Catabolism Anabolism 30 g 30 g 30 g Breakfast Lunch Dinner Total protein 90 g Repeated maximal stimulation of protein synthesis increase/maintenance of muscle mass PaddonJones D, Rasmussen BB. Curr Opin Clin Nutr Metab Care. 2009;12(1):8690. PaddonJones D, Rasmussen BB. Curr Opin Clin Nutr Metab Care. 2009;12(1):8690.

Using Food First: Tips of the Trade Increase caloric density of meals Favorite and culturally appropriate foods Protein module Diet liberalization policies Proper dining environment Assistance and

include liquids, cookies, shakes, yogurts, bars, and puddings Realize that food and flavor fatigue is a documented malady Oral Nutritional Supplements Provided During Hospitalization Length of stay

7% decrease in probability of 30day readmissions *Monetary figures are based on 2010 US dollars and inflation adjusted. Readmission defined as return to study hospital for any diagnosis.

5 Using Food First: Tips of the Trade Increase caloric density of meals Favorite and culturally appropriate foods Protein module Diet liberalization policies Proper dining environment Assistance and encouragement as needed Oral Nutrition Supplements Fill in the Gaps Serve cold over ice Serve in a glass or goblet Vary flavors using gelatin powder mix or fruit drink powder mix Vary textures to include liquids, cookies, shakes, yogurts, bars, and puddings Realize that food and flavor fatigue is a documented malady Oral Nutritional Supplements Provided During Hospitalization Length of stay (LOS): 21% decrease in LOS (2.3 days) Micronutrients: To Supplement or Not? Episode cost: 21.6% decrease in episode costs ($4734)* Readmissions: 6.7% decrease in probability of 30day readmissions *Monetary figures are based on 2010 US dollars and inflation adjusted. Readmission defined as return to study hospital for any diagnosis. Data measured delayed readmission and does not include patients not readmitted because of recovery or death. Philipson TJ et al. Am J Manag Care. 2013;19(2): EscottStump S. Nutrition and DiagnosisRelated Care. 7th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; Micronutrients in Wound Healing Daily multivitamin Multivitamin to provide 100% RDAs/RDIs Vitamins Vitamin C helps collagen synthesis and tensile strength Vitamin A helps epithelialization and fibroblast stimulation Minerals Zinc protein synthesis Copper collagen production and crosslinking Manganese collagen and ground substance Zempleni J, Suttie JW, Gregory III JF, Stover PJ, eds. Handbook of Vitamins. 5th ed. Boca Raton, FL: CRC Press; Cell Signaling TOR (target of rapamycin) 1 : Protein kinase Central element in a signaling pathway, which controls cell growth and proliferation mtor=mammalian target of rapamycin TOR signaling is activated by key functional amino acids 2 : Arginine Glutamine Leucine 1. Wullschleger S et al. Cell. 2006;124(3): Jacinto E, Hall MN. Nat Rev Mol Cell Biol. 2003;4(2):

Classification of Amino Acids IAA Histidine Isoleucine Leucine Lysine Methionine Phenylalanine Threonine Tryptophan Valine DAA Alanine Aspartic acid Asparagine Glutamic acid Serine CIAA Arginine

Intracellular Signaling Support for Immune Function Protein biosynthesis Vasodilates blood vessels Is directly bactericidal Enhances IGF1 Increases vascular permeability Is used by macrophages and

6 Classification of Amino Acids IAA Histidine Isoleucine Leucine Lysine Methionine Phenylalanine Threonine Tryptophan Valine DAA Alanine Aspartic acid Asparagine Glutamic acid Serine CIAA Arginine Cysteine Glutamine Glycine Proline Tyrosine 3 Major Functions of Arginine in Wound Healing Arginine Is a Key Amino Acid for Metabolic Pathways Stimulant for Wound Healing Nitric Oxide Production for Intracellular Signaling Support for Immune Function Protein biosynthesis Vasodilates blood vessels Is directly bactericidal Enhances IGF1 Increases vascular permeability Is used by macrophages and leukocytes to destroy pathogens Mediates growth hormone Reeds PJ. J Nutr. 2000;130(7):1835S1840S. Patel JJ et al. Nutr Clin Pract. 2016;31(4): Role of Glutamine in Wound Healing Glutamine may become depleted in patients with 1 : Critical illness Increased metabolism demand Protein catabolism Glutamine is the most abundant amino acid in the body 2 : >20% total circulating amino acids >60% intracellular amino acids Role of Glutamine in Wound Healing (cont d) Benefits of supplemental glutamine related to wound healing include: Stimulation of collagen synthesis Regulation of nitrogen metabolism in catabolic states Immune support Gut integrity 1. Mundi MS et al. Nutr Clin Pract. 2016;31(4): Buhaescu I et al. Ther Drug Monit. 2006;28(5): Escobar J et al. Am J Physiol Endocrinol Metab. 2005;288(5):E914E921. βhydroxyβmethylbutyrate (HMB) human clinical trials over the past 30 years Metabolite of amino acid leucine: Occurs naturally in human muscle cells Found in small amounts in many foods (eg, avocado, grapefruit, catfish) Inhibits intracellular protein degradation in muscle and supports intracellular protein synthesis in muscle by: Reducing the inflammatory response Protecting muscle from breakdown Protecting muscle from stressrelated damage 1. Nissen SL, Abumrad NN. J Nutr Biochem. 1997;8: Wilson GJ et al. Nutr Metab (London). 2008;5:1. 3. Eley HL et al. Am J Physiol Endocrinol Metab. 2008;295(6):E1409E Deutz NE et al. Clin Nutr. 2013;32(5): Effect of HMB on Muscle Mass and Strength During Bed Rest Objective: To investigate the effect of HMB on muscle mass and strength that occur during 10 days of bed rest To investigate the effect of HMB (plus exercise) on muscle recovery following the bedrest period Study design: Randomized, doubleblinded, controlled study Healthy elderly subjects (60 to 77 years of age; average=68 years) CaHMB (3 g/day) vs control 24 subjects (20 women; 4 men) Deutz NE et al. Clin Nutr. 2013;32(5):

Effect of HMB on Muscle Mass and Strength During Bed Rest (cont d) Costs: Putting It in Perspective Add nutrition interventions to your wound care protocol Therapeutic nutrition

Brem H et al. Am J Surg. 2001;200(4):473477.

7 Effect of HMB on Muscle Mass and Strength During Bed Rest (cont d) Costs: Putting It in Perspective Add nutrition interventions to your wound care protocol Therapeutic nutrition is a highly costeffective intervention to help prevent and treat PIs Brem et al reported cost of Stage 3 or 4 PI at $127,185 Deutz NE et al. Clin Nutr. 2013;32(5): Brem H et al. Am J Surg. 2001;200(4): Costs: Putting It in Perspective (cont d) If nutrition therapy costs $5/day, you could provide nutrition for 25,437 days (69 years) at an equal cost to treat one PI Questions? Let s Talk About Nutrition drnancycollins Light Bulb Health Brem H et al. Am J Surg. 2001;200(4):

Why is Protein Important?

Title Pearls Protein Why is Protein Important? Only nutrient containing nitrogen Responsible for synthesis of enzymes involved in wound healing and collagen synthesis Needed at every step of the healing