Transcript Nutrition and Dietary Advice – Angela Reddy

Action Duchenne Conference 2015
Nutrition and Dietary Advice
Angela Reddy
Senior Specialist Dietitian
Lane Fox Respiratory Unit
St Thomas’ Hospital
Guys and St Thomas’ Foundation Trust
Lane Fox Respiratory Unit
Specialists in Chronic Respiratory Care
Est. 1989
Varied: both sides of the nutritional spectrum
>5 yrs
loss
ambulation
and steroids
1 yr
 Healthy-eating
 Dietary advice
> 14/5
yrs
20 yrs
onwards
Weight increasing
dietary advice
Tracey Davis, Specialist Dietitian, GOSH
Introduction
• Nutrition is a critical part of long term DMD management
•
Both malnutrition and obesity are harmful to respiratory
function
•
Overweight/obesity (BMI of more than 25kg/m2)
 Impedes breathing and increases the work of the
respiratory muscles/Spinal jackets become too
tight/Decreased mobility/Increased difficulty for carers
to lift
Introduction
• Malnutrition is acknowledged as a predictor of adverse
outcomes in patients with neuromuscular diseases (BTS, 2002)
• Malnutrition is a key feature of chronic respiratory disease
• It adversely affects respiratory muscles, reducing muscle
mass and strength
• It additionally affects immune function, wound healing,
sensitivity to oxygen prolonging ventilator weaning and
psychosocial function
• Poor nutritional status is associated with non invasive
ventilation (NIV) failure.
Child with DMD
>5 yrs
loss
ambulation
and steroids
1 yr
 Healthy-eating
 Dietary advice
Nutrition advice
Overweight in DMD
•
Weight increase tends to coincide with
• Loss of ambulation
• Steroid therapy (effects on appetite)
• Around 8 - 12 years of age
•
What causes one to become overweight?
• Energy balance: Energy in = energy out
• Increased appetite (steroids)
• Reduced mobility
•
Always difficult to lose weight ESPECIALLY if mobility
affected
Therefore, prevention better than cure!
•
Tracey Davis, Specialist Dietitian, GOSH
Overweight in DMD
•
Parents/carers/family can help
• Can become pro-active in preventing excessive weight
gain
•
How?
• By following a “healthy eating” diet
Tracey Davis, Specialist Dietitian, GOSH
Healthy Eating
Meat &
Alternatives
Starchy
Foods
Vegetables
& Fruit
Traditional Meal
Unhealthy meal
proportions
Meat &
Alternatives
Starchy
Foods
Vegetables
& Fruit
Healthy
‘Balanced’ Meal
Changing the
proportions of food
in this way leads to a
healthier meal
Meat &
Alternatives
Starchy
Foods
Vegetables
& Fruit
Weight Reducing Meal
Changing the proportions in
this way will reduce energy
intake, help you lose weight,
but allow you to eat the
same volume of food
Tracey Davis, Specialist Dietitian, GOSH
Hidden fats
1 pat = 5g
High Fat Products
Low Fat Alternatives
2 sausages, pork (fried)
4 fish fingers (grilled)
60g chocolate bar
Crunchie bar
60g nuts (large handful)
60g raisins
Tracey Davis, Specialist Dietitian, GOSH
Hidden sugars
1 cube = 5g of sugar
Small bowl of Frosties
Small bowl of All-Bran
1 slice Victoria Sponge
1 currant bun
8 oz tinned fruit in syrup
8 oz tinned fruit in juice
Tracey Davis, Specialist Dietitian, GOSH
Healthy Eating
• Low glycaemic index (GI) food
• Ranks how carbohydrate rich food affects blood
levels
• Slowly absorbed food have a low GI rating.
• Keeps you fuller for longer
Barley
Fruit
Yam/
Sweet Potato
Barley
Basmati Rice
Slowly absorbed
starchy food
Porridge, oats
based cereals,
All Bran and
Sultana Bran
Beans & Lentils
Pasta & Noodles
Wholegrain Bread
(Bread with ‘bits’
i.e. Pumpernickel
or granary)
Tracey Davis, Specialist Dietitian, GOSH
Adolescent/Adult with DMD
1 yr
20 yrs
onwards
> 14/15
years
Weight increasing
dietary advice
Underweight or malnutrition
•
Malnutrition or protein-energy malnutrition
 A condition of decreased body stores of protein and
energy (calorie) furl stores – i.e. lean body mass and
fat mass
 In developed countries disease is the principal cause
•
Nutritional intake may be compromised due to the
inflammation imposed by the chronic disease
•
This loss of LBM associated with inflammation and
functional impairment is considered disease related
malnutrition – a significant problem in respiratory and
neurological disease
Underweight or malnutrition
•
Malnutrition common in DMD adults
•
Protein energy malnutrition is classified:
 As a body mass index (BMI) of less than 18.5 kg/m2
 Unintentional weight loss of greater than 10%
 A BMI of less than 20 kg/m2 and unintentional weight
loss of greater than 5% within the last 3-6 months (NICE,
2006)
• BMI of less than 20kg/m2-commonly used in clinical
practice
• Malnutrition is common in hospitalised patients and
associated with poor outcomes
Effects of malnutrition
Feeding and nutritional problems are common
•
Chewing fatigue
•
Prolonged meal times accompanied by drooling and
spilling
•
Dysphagia and aspiration
•
Inadequate nutritional intake
•
Weight loss as disease progresses
•
Constipation
•
Gastric and intestinal dilatation
•
Gastro-oesophageal reflux
•
Timely consideration of gastric tube feeding is necessary
Malnutrition risk
•
Nutritional needs or requirements (protein and energy)
are increased
 During illness and infection
 Surgery
 Increased work of breathing
• In clinics and on the ward, we screen patients (weight,
weight loss, eating less than normal) to detect those with
or at risk of malnutrition
• Early identification is essential to provide help and correct
nutritional issues
Assessment of nutritional status
•
Assessment of nutritional status provides information
on severity and causes of malnutrition
 Low body weight/reduced total fat/decreased
muscle mass
 Anthropometry
 % Weight loss
 Low energy or protein intakes
 Biochemical
 Clinical conditions
What can we do?
• Prevent weight loss/aid weight gain via manipulation of the
diet
Increase frequency of consumption of nutrient-dense
snacks
Plus encourage milky drinks/condensed soups
Try 3 meals plus 2-3 snacks
Increase nutrient density of foods
• Fortifying foods
• Adding nutrients e.g., fats/add protein to food
• Add multivitamins such as Forceval soluble
• Avoid low calorie drinks e.g., tea/coffee
• Prevent weight loss/aid weight gain via nutritional
supplements
 Not as a meal replacement, but in addition to normal
intake
• High calorie high protein supplements
 Fortisip Compact Protein has 300kcal and 18g protein in
125ml (60ml x 2 shots)
 Fresubin 2kcal has 400kcal, 20 g protein in 200ml
 Scandishake has 600kcal, 12 g protein (250ml) – can add
ice cream, strawberries and liquidise
 High calorie drinks – juice based in 200ml
 High calorie fat supplements such as Calogen, Procal in
30ml shots x 3 per day
 Use supplements in recipes
• Regular preventative nutritional therapy recommended
• Prevent weight loss/aid weight gain via enteral nutrition
 Short or long term
 Via Nasogastric tube or gastrostomy
 Might aim to meet 100% of requirements in initial stage
of feeding
 Transition to oral feeding in short term enteral
feeding
 Laxatives
 Prokinetic agents
Monitor! Monitor! Monitor!
•
Admission and weekly nutritional screening
•
Weights: weekly on the ward or in clinic
•
Intake - if adequate nutritional intake on food charts
•
Bowels!!
•
Fluids
•
Vomiting
•
Nutritional requirements
•
Fatigue
•
Meal timing
•
NG and gastrostomy care
•
Daily MDT
Gastrostomy or PEG feeding
• It is a feeding tube inserted through the stomach wall into the
abdomen for the purpose of nutrition support
• Can be done using an endoscope, and is referred to as a
percutaneous endoscopic gastrostomy (PEG)
• A PEG might be required due to the common nutritional
problems mentioned above
• It is there to support normal eating and not to replace it
• People report feeling very excited
– that they can eat what they enjoy at mealtimes and at their own pace
– Eating and gaining weight
• It is frequently used to take medications and additional water
• Feed regimens are varied and is designed to suit the individual
• Some people prefer overnight feeding whilst some prefer
daytime or bolus feeding or combination of both
• Different types of gastrostomy tubes such as, low profile devices
sit flush with the stomach and is not noticeable under the clothes
• All discreet
When do we insert
gastrostomy feeding tubes?
Retrospective Study of Nutritional
Status and Outcomes in DMD with
Chronic Respiratory Failure
To assess the nutritional risk status of adult patients with DMD
and chronic respiratory failure and to investigate its association
with hospital outcomes over a 12-month period
Methods
•
Retrospective case series study using hospital records
•
Nutritional parameters:
 weight
 body mass index (BMI)
 feeding route (enteral or oral)
•
Hospital outcome measures:
 cumulative length of hospital stay (LOS)
 ventilator adherence (hours)
 frequency of admission
 forced vital capacity (FVC)
 mortality
RESULTS
Clinical Variable
Data available
(n)
Mean ± SD /Median
(IQR)
Age (years)
79
21 (19-24)
Current weight (kg)
68
57 ± 16
Baseline weight (kg)
55
53.4 (52.3-62.7)
Weight change
55
0 ± 1.2
BMI (kg/m2)
34
21.9 (17.3-24.8)
• 30/79 (38%) were oral fed and 24/79 (30%) were
PEG fed
Clinical Variable
Data available
(n)
Mean ± SD /Median
(IQR)
LOS (days)
79
2 (0-14)
Infection episodes
34
0 (0-1)
FVC (L)
46
1.2 (1.3)
Time on respiratory
support (hours)
59
10 (8.1-17)
Enteral tube fed patients (n=30) had a greater
admission risk compared to oral (n=49) fed patients
Age (years)
Current weight
(kg)
Baseline
weight (kg)
BMI (kg/m2)
Annual LOS
(days)
Total
admissions
Chest Sepsis
Episodes
Ventilator time
(hours)
FVC (L)
Enteral
Oral
P value
23.5 (20,25)
21.7 (19,23)
0.06
52 (18)
61 (14.5)
0.03*
45 (35, 67)
61 (51, 71)
0.02*
21 (15, 24)
23 (19, 26)
0.2
11 (0,36)
0.5 (0,8)
0.004*
2.0 (0, 3)
1.0 (0, 2)
0.03*
1 (0,1)
0 (0,1)
0.04*
14.0 (10, 24)
8.9 (6, 12)
0.001*
0.5 (0.4, 0.7)
0.9 (0.6, 2.0)
0.001*
•
Weight in patients admitted to hospital was less than those nonadmitted patients
•
Admission risk was greater in the underweight (BMI<20kg/m2)
or overweight (BMI>25kg/m2) patient groups compared to
normal BMI patients
•
There was an association between weight and feeding method:
- patients with higher weights were associated with decreased
risk of enteral feeding
- Enteral feeding was associated with an increased non-invasive
ventilator use per day and LOS
Conclusion
• Malnutrition is a potentially neglected clinical area in this cohort of
patients with incomplete recording of nutritional data
• Weight was associated with adverse outcomes in DMD
– Overweight and underweight patients were more likely to be
admitted than those with a normal body habitus
– Patients who are enterally fed had a greater admission risk,
infective episodes and LOS than orally fed patients, indicative of
disease severity
• Future prospective research to assess nutritional status and hospital
outcomes is recommended
• Regular nutritional monitoring and intervention may improve
patient outcome
Where do we insert gastrostomy
feeding tubes?
Lane Fox Approach
• Currently
– Assessed in outpatients by doctor, transitional NMD specialist,
nurse and dietitian
– Weighed at each visit (in wheelchair)
– Focus on feeding issues and malnutrition
– Assessed as inpatient only by SLT
– PEG tubes inserted on the unit by Lane Fox Gastrostomy
Insertion Team (Lane Fox Consultant, Gastroenterology
Consultant, Anesthetic Consultant)
– 4 insertions per month
• New
– Dietitian part of outpatient assessment team
– To screen and identify those requiring aggressive nutritional
support
– Develop care pathway for nutritional support in DMD
Gastrostomy Feeding - When and Where?
• Enteral feeding is initiated when adequate oral
nutritional cannot be safely accomplished
• There is a need for early assessment for gastrostomy
insertion and guidelines for insertion in adult DMD
• Early insertion of feeding tubes should be considered
as this may potentially reduce the risks associated
with enteral feeding
• Further studies are required to establish the optimum
time to initiate enteral feeding
Are there guidelines to help?
•
•
•
•
Action Duchenne
Treat NMD
Muscular Dystrophy Campaign
Some guidelines for DMD, however
– Adequate nutritional status described as weight to age ratio or BMI for age
from the 10th to the 85th on national percentile charts
– Gastrostomy is recommended when weight and hydration can no longer
be met by oral means
– Managing complications in adults is acknowledged but recommendations
are centred on children (Bushby et al, 2010)
– Nutrition is highlighted as a critical aspect of long-term DMD care
– Emphasises lack of reliable evidence exploring malnutrition and nutritional
assessment in adults
– Lack of nutritional consensus and practice guidelines is highlighted
– Limited evidence examining gastrostomy feeding (American Thoracic Society,
2004)
Constipation
• Increase sources of fibre, which
–
–
–
–
Alleviates constipation
Has a bulking action
Holds water – increasing stool weight
Facilitates bowel regularity
• Sources - wholegrain foods such as oats, seeds
(linseeds/flaxseeds), potato skins, lentils, pulses, fruit with
edible seeds, vegetables (beans, cauliflower, courgette,
celery, peas)
• Oats and linseeds do not produce gas/do not bloat
• Increase fluid to at least 6 – 8 glasses per day
Novel foods
• Co-Enzyme Q10
• Vitamin-like substance in the mitochondria or the
“powerhouse” of the cell
• No proven use for strengthening muscles in DMD:
 Cooperative International Neuromuscular Research Group
pilot trial only
  muscle strength, but numbers very small (12/13
completed)
 Not controlled study!
Tracey Davis, Specialist Dietitian, GOSH
Novel foods
• Creatine
• Role - supplies energy to body via increasing ATP
(energy) formation
• Weak evidence in MD - no evidence it increases muscle
strength
• The Cochrane review (Kley, Vorgerd and Tarnopolskyonly, 2007)
included 1 study in patients with MD.
• We do not know the dose, how long to give it for and after
effects.
• Very little research into its effectiveness and safety – not
recommended
Overall conclusion
• Malnutrition common
• Referral
• Food –> nutritional supplement drinks –> enteral
feeding
• Monitor! Monitor! Monitor!
• Regular
preventative
recommended
nutritional
therapy
is
Any Questions?