Nutrition in Special Conditionsreviews.berlinpharm.com/20170311/Nutrition_in_Special_Conditions.pdf · 3/11/2017 · Nutrition in Special Conditions Prapimporn Ch. Shantavasinkul

10/03/60

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Nutrition in Special Conditions

Prapimporn Ch. Shantavasinkul MD, MHS

Division of Nutrition and Biochemistry, Department of Medicine, Faculty of medicine,

Ramathibodi Hospital, Mahidol University

[email protected] march 2017

Outlines

Obesity

Medical Therapy

Bariatric Surgery and complications

Undernutrition

Nutritional screening & assessment

Nutrition in special conditions

Nutritional deficiency

OSA, OHS

GS, GERD

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Classification Asian Caucasian

BMI (Kg/m2)

Underweight <18.50

Severe thinness <16.00

Moderate 16.00 - 16.99

Mild thinness 17.00 - 18.49Normal 18.5-22.9 18.5 – 24.9

Overweight 23-24.9 25-29

Obese I >25 >30

Obese II >30 >35

Morbid obese >40 >40

Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004.

Abdominal obesity

Waist circumference

> 80 cm in woman

> 90 cm in men

How to lose weight

Diet and Life style modification

All overweight and obese patients

Pharmacotherapy (after diet for > 3 months)

BMI > 30 kg/m2

BMI > 27 kg/m2 plus comorbidities

Weight loss surgery

Fail medical Rx + No contraindication

BMI > 40 kg/m2


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Diet for Weight Loss

Very low calorie diet: <800 calories/d

Low calorie balance diet:

500 or 1000 deficit; 1200‐1500 calories/d

Low fat diet

Low carbohydrate ketogenic diet: Atkin diet

Meal replacement

Red- low fat, moderate protein

Blue – low fat, high proteinOrange – high fat, moderate proteinYellow – high fat, high protein

Attendance at group sessions strongly predicted weight loss at 2 year

Sack FM et al. NEJM 2009: 360; 859-73

Weight Loss Medication

Always combine medication with diet and

life style changes

After discontinue medication may regain

Try diet and exercise for at least 3 months

If lose weight > 10% by diet and exercise

no need to start medication

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Phentermine since 1959

1999 2012 2012 2014 2014

Xenical Belviq Qsymia Contrave Victoza/Saxenda

HT and CVD Migrain

seizureDepression T2DM

Caution: Weight Loss Medications

Females of childbearing potential

LMP or pregnancy test

Ask if patients have suicidal ideation

Hypoglycemia: weight loss/ caloric reduction

Monitor glucose, adjust medication as appropriate

Weight Loss Medications

Apovian CM et al. Obesity 2015:23;s1-s26

Agent Mechanisms of Action

Phentermine Increase Dopamine, NE release and inhibit reuptake

Take before 9 AM titrate from 7.5 to 30 mg/day

Oristat Peripheral pancreatic lipase inhibitor

Decreased fat absorption 30%, -10.6%at1y, -5.8%at4 y

Lorcaserin Selective serotonin receptor agonist (5-HT2c)

Phentermine/topiramate ER

(3.75/23), (7.5/46),

(11.25/69), (15/92)

Sympathomimetic/Anticonvulsant

(7.5, 46) - 10% to (15/92) -12 % at 2 yr

Titration period is 2 week for each dose

Natrexone ER/bupoprion ER(8mg /90 mg)

Opioid receptor antagonist

Dopamine/noradreanaline reuptake inhibitor1 tablet/d titrate up to 2 tab oral bid

Liraglutide 3.0 mg GLP-1 receptor agnoist

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Weight Loss Medications

Apovian CM et a;l. Obesity 2015:23;s1-s26

Agents Medical conditions

Oristat HT or cardiovascular diseases

Lorcaserin HT or cardiovascular diseases

Phentermine/topiramate ER Migrain, seizure

Natrexone ER/bupoprion ER Depression

Liraglutide 3.0 mg T2DM, add on Metformin

Consider SGLT-2 inhibitor

If patient need insulin prefer basal insulin and consider add metformin, pramlintide, or GLP-1 agonists

Contraindication to Use of

Weight Loss Medications a


Agent Contraindications

Oristat Pregnancy, malabsorption, cholestatis

Lorcaserin PregnancyRisk of serotonin syndrome (not use with SSRI, MAOI)

Phentermine/topiramate ER Glaucoma

HyperthyroidismWithin 14 days of taking MAOI

Natrexone ER/bupoprion ER Pregnancy

Uncontrolled HT

Seizure, anorexia nervosa, bulimiaAbrupt discontinuation of alcohol, benzodiazepine,

antiepileptic

Use of bupropion-containing product, or use of opioidWithin 14 days of taking MAOI

Liraglutide 3.0 mg Pregnancy, FH of MTC, patients MEN2

Follow up


Follow up monthly x 3 then q 3 months

Discontinue medications if

Ineffective: loss < 5% of initial BW at 3 mo

Intolerability or safety issues

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Bariatric Surgery

Malabsorptive SurgeryRestrictive Surgery

•High risk esp. in BPD/DS

•Fat malabsorption : ADEK•B1, B12, folate, iron def.

•Risk : B12, iron def

•B1 deficiency

Weight Loss Surgery

BMI > 40 kg/m2


Fail to lose weight by medical therapy

(multiple attempt)

Exclusion: Drug, alcohol abuse, uncontrolled

psychiatric&eating disorder, endstage disease

Endocr Pract 19, 337-72 (2013)

Bariatric Surgery Candidates

• Motivated, well-informed patients with

realistic expectations

• Commitment of long term follow-up

• Stop smoking preoperatively

• Avoid NSAIDs

• Child bearing age woman need to use non-

oral contraception for at least 12-24 months

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Sleeve Gastrectomy

RYGB(70 % in US)

gastrojejunostomy+Jejunojejunostomy

N Engl J Med 2007;356:2176-83

30 ML, 1 cm outlet

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Early Post-operative Care

• Dehydration, constipation, food intolerance

• HBPM, observe postural hypotension

• SMBG, observe hypo-, hyperglycemia

• Anti-hypertensive and diabetes-related

medications may be stopped or dose modified

in the immediate postoperative period

• Other medications may need dose

modification (thyroid hormone, warfarin, etc)

O'Kane M et al. Clinical obesity. 2016;6(3):210-24.

Longterm Monitoring

Gall stone

Kidney stone

Dumping syndrome

Post-bariatric surgery hypoglycemia


Dumping Syndrome

Early dumping (within 15-30 min)

colicky abdominal pain, diarrhea, nausea, and

tachycardia

Post gastric bypass hypoglycemia(2 hrs)

Postprandial hypoglycemia

Hyperglycemia and the subsequent insulin

response leading to hypoglycemia that occurs 2

to 3 hours after a meal. Patients present with dizziness, fatigue, diaphoresis and weakness.

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Bariatric Surgery

Symptomatic nutritional def is RARE

Non-compliance patients

Reversible & rapid recovery if early diagnosed

If left untreated, irreversible or death

Obesity with micronutrient deficiency is not uncommon

Nutritional Deficiency in Bariatric Surgery

Persistence of pre-operative deficiency

Obesity but inadequate micronutrient, protein intake

Pre-operative weight loss without supplement.

Protein, iron and vitamin D deficiency

Post-surgery

Poor quality of diet

Altered digestion and absorption ( HCl, IF)

Adherence to vitamin and mineral supplement

Small intestinal bacterial overgrowth

Alcohol, substance abuse and eating disorder

Edward Saltzman et al. Annu. Rev. Nutr. 2013. 33:183–203

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Calcium

IronProteinCarb.

Terminal IleumB12 & Bile Salts

Fat

Vit. A,D,E,K

Water sol vit.Folate

Mineral

CopperZn, P, Mg

Nutritional

Deficiency after

Bariatric Surgery

Post Bariatric Surgery

Supplementation

AACE/TOS/ASMBS Guidelines. Obesity 2013; 21;S1-27

Multivitamin daily : all vitamin, mineral

B1, folic acid, Zn, Copper, Selenium, iron

○ RYGB, BPD 2 tablets/day

○ ABG, SG 1 tablet/day

Ca-citrate, 1200-1500mg/d of elemental Ca

Vit D, at least 3000 units/d, (>30 ng/mL)

Vit B12 500-1000 mcg/day

Iron 45-60 mg/day

Thiamine

Water soluble vitamin

It is not stores in body

it is required daily

High conc in brain,heart

Liver, renal, muscle

Function is related to

Metabolism esp. CHO

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“Bariatric Beriberi”

Asymptomatic low B1 level 0-29% (pre-op), 10-

56% (post-op)

Storage 3-6 wk early deficiency

Risk: rapid wt loss, poor intake, persistence

vomiting, no supplement , alcohol(uncommon)

hyperemesis gravida, chronic dis, diuretic, PN (without vitamin supplementation)

Less likely from malabsorption

Report cases of beriberi, Wernicke & Korsakoff,

peripheral neuropathy occurred months to years

after all type of surgeries

Thiamine Deficiency

Beriberi

Dry ; peripheral neuropathy

Wet ; high output heart failure, lactic acidosis

Wernicke’s encephalopathy

Ataxia, opthalmoplegia, nystagmus

Korsakoff’s psychosis

Initial or sequalae of WE

Diagnosis of Thiamine def

Serum thiamine : reflect daily intake>storage

Normal cannot exclude B1 def.

Erythrocyte transketolase activation assay (ETKA)

Before and after adding TPP

Thiamine pyrophosphate effects (TPP)

A greater than 15-20% increase in activity with TPP

indicates B1 deficiency

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Clinical Response

Diuresis immediate

High output HF 24 h

Opthalmoplegia 24 hours

Neurological symptoms several weeks or

months (permanent if delayed Rx)

• megaloblastic anemia, hypersegmented neutrophil

Hematologic

• glossitis, chelitis , hair depigmentation, hyperpigment

Mucocutaneous

• weakness, paresthesia, ataxia,dementia

Neurologic

B12 and Folate

Only B12

Combined B12 and Folate Def is common

Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 9th ed

Free B12

Bind to Intrinsic

Factor

Bind to

R-protein

Free B12

99% can be absorbed with

IF at ileum, 1% can be absorbed at all small bowel

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Sally P. Stabler, Vitamin B12 Deficiency. NEJM 2013;368:149-60.

Chronicpancreatitis

Pernicious

Gastrectomy

RYGB

Atrophic gastritis

acid-blocking drug

Vegan, BF

Ileum

Lesion/ResectionSIBO

parasite

Diagnosis B12 deficiency

Onset 2-3 years since high amount of liver storage

Reported B12 def case 1 year post bariatric surgery

B12 < 200 pg/mL indicate B12 deficiency

Normal B12 level cannot exclude clinical deficiency

Should check MMA elevated MMA in early B12 def

and MMA decreases afrer B12 therapy

Hyperhomocystein is non-specific

*DDx B12, folate and B6 deficiency

B12 Folate

Storage 2,000-5,000 mcg 5,000-10,000 mg

Requirement 2.4 mcg 400 mcg

Liver Storage : requirement

1000 : 1 50: 1

Food Source Animal Vary

Absorption Need IF, Ileum Vary

Time to deficiency 2-3 yrs 4 wks - 4 mths

MegaloblasticAnemia

Yes Yes

Neurological symptom

Yes No

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Copper Deficiency after Bariatric

The prevalence is 4-10%, incidence 19% (2y)

Bypass duodenum decrease absorption

Anemia (micro, normo, macrocytic), leucopenia,

pancytopenia

Myelopathy with spastic gait, sensory ataxia

Peripheral/optic neuropathy, cognitive impairment

Prognosis; rapid improvement in hematologic

system but not neurological improvement

Supplement Cu 1mg to Zn 8-15 mg (2mg/d)No need to screen in aymptomatic pt.

Outlines

Obesity

Medical Therapy

Bariatric Surgery and complications

Undernutrition

Nutritional screening & assessment

Nutrition in special condition


Jensen GL, et al. JPEN. 2009;33(6):710-6

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Short Bowel Syndrome

Intestinal failure

Small bowel length < 200 cm

malabsorption due to insufficient intestinal

surface area

severe SBS necessitating longterm PN 2-4 cases

per 1 million persons per year, based on

multinational European data

Society of Parenteral & Enteral Nutrition of Thailand

http://www.spent.or.th/index.php/public

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NAF A (scores 0-5) normal-mild malnutrition

Reevaluation in 7 days

NAF B (scores 6-10) moderate malnutrition

Nutrition support within 3 days

NAF C (scores ≥ 11) severe malnutrition

Nutrition support within 24 hours

http://www.spent.or.th/index.php/public


Hasse, J.M. et al. Nutr Clin Pract 2015: 30; 474-87Subcutaneous fat : periorbital, triceps, biceps, chest

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Hasse, J.M. et al. Nutr Clin Pract 2015: 30; 474-87Rib do not show

Prominent ribs

Shapiro J. N Engl J Med 2007;357:1620-1630.

Hair Pulling Test

Approximately 60 hairs are grasped between the thumb, index finger, andmiddle fingers near the scalp

Deficiency:

Protein, Biotin, Zinc

Total Energy Expenditure

Resting/basal energy expenditure 60%

Associated with lean body mass

Activity induced energy expenditure 30%

Depend on physical activity

Diet induced energy expenditure 10%

Indirect caloriemetry

Measure O2 consumption and CO2 production

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Energy Requirement

Basal Energy Expenditure (BEE)

Indirect calorimeter

Harris-Benedict Equations

ACCP (American College of Chest Physicians) 25 kcal/kg/d

Total Energy Expenditure (TEE)

TEE = BEE (x AF) x IF

AF = Activity Factor

IF = Injury Factor (or Stress Factor)

Energy Requirement

Normal 25-30 kcal/kg/day

Mild stress 30-35 kcal/kg/day

Severe stress 35-40 kcal/kg/day

Critically-ill 25-30 kcal/kg/day

Normal 0.8-1 g/kg/day

Stress 1.2-1.5 g/kg/day

Burn, trauma 1.5-2 g/kg/day

Beware : AKI, CKD, hepatic encephalopthy

Protein Requirement

Re-feeding syndrome (RFS)

Symptoms of RFS occur from fluid and

electrolyte imbalances resulting from

nutritional supplementation following a

period of prolonged starvation in

malnourished patients.

Onset 2-6 days after nutrition support

Oral, enteral, or parenteral routes

Nutrition 26 (2010) 156–167

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Patients at Risk for Re-feeding Syndrome(RFS)

Nutrition in Clinical Practice 2005; 20: 625–33,

Refeeding syndrome (RFS)

HypoP ventilatory failure, rhabdomiolysis

HypoK arrhythmia, ventilatory failure, rhabdomiolysis, ileus

HypoMg cardiac arrhythmia, rhabdomiolysis

Na & water retention and fluid overload, CHF

Thiamine def. Beri beri, WE

The hallmark : severe hypophosphatemia

Nutrition 26 (2010) 156–167

Prevention and Rx of RFS

Nutrition 26 (2010) 156–167

Recognize Patients at Risk

Electrolyte replacement

Fluid and sodium balance

Energy : avoid overfeeding (dec cal 50%)

Vitamins and trace elements supplement

Monitoring and following up

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BMI = BW

(Ht x Ht)2

Normal BMI 18.5 -23 kg/m2

Ideal BW = 18.5 x (Ht x Ht)2

= 23 x (Ht x Ht)2

if underweight 18.5 x (Ht x Ht)2

If overweight/obesity 23 x (Ht x Ht)2

IBW = Height – 100 (M) , Height – 110 (F)

Goal of Nutrition Support in Obesity

Muscle protein catabolism is a hallmark feature

of critical illness, regardless of BMI

(losses 10–20% of muscle after 1 wk in ICU)

Hypocaloric feeding : avoid potential

complications associated with overfeeding

› Hyperglycemia, hyperTG, CO2 retention

Optimal protein to prevent lean body mass loss

Miller et al, Respir Care Clin 12 (2006) 593–601

McClave SA JPEN J Parenter Enteral Nutr. 2016;40:159-211.

Obesity in Critical Illness

Calories (IC is the best, use 60-70% of TEE)

BMI 30-50 kg/m2 : 11-14 kcal/actual BW/d.

BMI > 50 kg/m2 : 22-25 kcal/ Ideal BW/d using the equation for ABW will overestimate if BMI > 50 kg/m2

Protein

BMI 30-40 kg/m2 : protein 2 g/ideal BW/d

BMI ≥ 40 kg/m2 : protein up to 2.5 g/ideal BW/d

McClave SA JPEN J Parenter Enteral Nutr. 2016;40:159-211.

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Essential Fatty Acids (EFAs)

LINOLEIC ACIDS (Omega 6)

18-carbon EFA that contain 2 double bonds

C18:3 n-3, need 3-4% of TC

LINOLENIC ACIDS (Omega 3)

18-carbon EFA that contain 3 double bonds

C18:2 n-6, need 0.5-1% of TC

Shills et al, Modern Nutrition in Health and Disease, 10th edition

Who are at Risk for EFA Deficiency?

Poor storage : Preterm infant Biochemical change/signs can develop within 5-10 days of life

Increases metabolic demands

Rapid growth: Preterm infant (poor storage)

Stress, sepsis, injury

TPN without lipid infusion

Very rare in chronic starvation


TPN without Lipid Emulsion

Starvation insulin lipolysis

Continuous glucose infusion insulin

inhibit lipolysis and depress EFA release from

adipose tissue

Only amino acid infusion does not produce EFAD


Triene :Tetraene Ratio > 0.2

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Clinical Signs of EFAD

Alopecia

Scaly dermatitis

Intertriginous erosions

Increase capillary

fragility (peitichiae)

Poor wound healing

Increased Platelet

aggregation

Increased susceptibility

to infection

Poor inflammatory

response

Fatty liver

Growth retardation

Weakness

Numbness

Impaired vision


N Engl J Med. 2005;353:616.

A 76-year-old man underwent elective repair of an

abdominal aortic aneurysm, 8 weeks later developed

exertional dyspnea, orthopnea, and abdominal pain

developed. PE : Right pleural effusion.Thoracentesis and paracentesis yielded a milky fluid

Anatomy of Thoracic Duct

Cisterna

Chyliant to L1-2

Abdominal Aorta

Thoracic Aorta

Thoracic duct

SVC

Lymphatic flow

1.5-2.4L/day

Flow is

increases with

diet intake esp.

Long-chain TG

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Diagnostic Features of Chyle

Milky appearance, odorless and sterile

may be serous or serosanguinous esp. fasting

TG > 110 mg/dL and > plasma TG

Cholesterol 65-220 mg/dL and < plasma chol.

Lipoprotein analysis: Chylomicron

WBC (400-6800cells/l)

T-lymphocytes>80%: bacteriostatic

RBC 50-600 cells/l)

Valentine VG et al. Chest. 1992;102:586-91.

Treatment of Chyle Leaks

Work up causes and specific treatment

Enteral nutrition (evaluate response in 7-10 d)

Low fat, supplementation with MCT (50-100ml/d)

Non-fat diet (<5kcal/serving), 20% of lipid emulsion

250 ml, 3 times/wk to prevent EFAD

NPO, PN (if EN failed or inadequate)

Micronutrient supplement in all cases (including ADEK)

+ Somatostatin analog?

Sriram K et al. Nutrition. 2016;32:281-6.

Nutritional support in adults with chyle leaks

MCT provides 8.3 kcal/g

Too much : diarrhea, ketosis, bloating

Fat soluble vitamin absorption : LCT

Essential fatty acid : LCT

LINOLEIC ACIDS (Omega 6)

○ C18:3 n-3, need 3-4% of TC

LINOLENIC ACIDS (Omega 3)

○ C18:2 n-6, need 0.5-1% of TC

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Chronic kidney diseases

Energy requirement (++/III)

Age < 60 yr : 35 kcal/kg/day

Age ≥ 60 yr : 30-35 kcal/kg/day

( Obese; BW > 120%IBW1 : 30 kcal/kg/day )

Protein requirement

eGFR < 30 ml/min/1.73m2 0.8 g/ kg of IBW/day (+/II)

High biological value protein at least 60% (++/III)

IBW : Height(cm)-100 (M), Height(cm)– 110 (F)

Na<2000mg/day(Salt 5 g/day)in edematous patients

Keep serum albumin > 3.5g/dL (check q 3-6 mo.)Bailey JL et al. Am J Kidney Dis.55:1146-61.

Vitamin and Mineral

Pre-dialysis

Pyridoxal HCl 5 mg, Folic 1 mg

Vitamin C 60 mg (too much will increase plasma

oxalate levels)

Vitamin A should not be supplemented

Vitamin K is not needed

Keep Vitamin D level > 30 pg/mL

Dialysis:vit C 75-90mg, pyridoxine10-50 mg/day

Bailey JL et al. Am J Kidney Dis.55:1146-61.

Hemodialysis (1)

Protein intake 1-1.2 g/kg/day

Nutrient losses

Amino acid losses are about 8-10 g during dialysis,

depending on the type of dialyzer

Glucose losses are removed about 25-30 g,

depending on the type of dialysate

B1, B2, B6, vitamin C and folic acid are lost

B12 is protein bound so B12 lost is negligible

Bailey JL et al. Am J Kidney Dis.55:1146-61.

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Peritoneal dialysis (1)

Protein intake should be 1.2-1.4 g/kg (with 50%

of high biological value)

Protein losses in peritoneal dialysate vary from

5-15 g/24 h (mainly albumin).

Protein losses may indirectly contribute to

various nutritional and metabolic disturbances

Absorption of glucose from dialysate (glucose,

100-200 g/24 h) : monitor glucose, IR

Obtain caloric goal and satiety

1.Bailey JL et al. Am J Kidney Dis.55:1146-61.

Reduced Intake- anorexia, n/v- Altered taste (Zn def)- Delayed gastric emptying- Inflamma. cytokines- Impaired conscious (HE)- Protein, salt restriction- Alcohol abuse

Cirrhosis liver-reduced gluconeogenesis-insulin resistance-hypermetabolism-muscle breakdown, immobilization

Tense ascite-postprandial discomfort

Malabsorption- Cholestasis- SIBO

Fasting- GI bleeding- Impaired conscious- Medical procedures

PCM in Chronic Liver Disease

Nutritional Assessment in Liver disease

Ascites, edema : BW

Albumin, prealbumin altered by liver disease

Subjective Global Assessment (SGA) or

anthropometry to identify patients at risk of

undernutrition.

Bioelectric impedance analysis (BIA) : some limitations in patients with edema, ascites.

ESPEN 2006. Clinical Nutrition (2006) 25, 285–294ESPEn 2009. Clinical Nutrition 28 (2009) 436–444

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Albumin Physiology in Critically ill Patient

Best Practice & Research Clinical Anaesthesiology 23 (2009) 183–191

• Energy 35-40 kcal/kg/d

• Protein 1.2-1.5 g/kg/d

• Fat MCT : steatorrhea or cholestasis

• Avoid fasting and protein restriction

• Small frequent meals throughout the day and a

latenight snack should be offered

• Oral BCAA supplementation to achieve protein goal in patients with dietary protein intolerant

Cirrhosis, Hepatic Encephalopathy

AASLD/EASL guideline. Hepatology. 2014;60(2):715-35.

Common in Cholestasis liver disease

• A, D, E, K, Calcium, Vitamin B

Common in Alcoholic liver disease

• Thiamine

• Folate

• Magnesium

• Zinc

• MTV, Zinc sulphate 25-50 mg in selected case

Cirrhosis, Hepatic Encephalopathy

AASLD/EASL guideline. Hepatology. 2014;60(2):715-35.

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Cancer Cachexia

Multifactorial syndrome: Loss of skeletal muscle mass (with

or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive

functional impairment.

Negative protein & energy balance: reduced food intake

and abnormal metabolism.

InflammationInvoluntary weight

loss of muscle (&fat)

Ryan AM et al. The Proceedings of the Nutrition Society. 2016;75(2):199-211.

ESPEN guidelines on Nutrition in Cancer Patients

Energy 25-30 kcal/kg/d, similar to healthy subjects

Higher REE but lower physical activity

Overestimated in obese

Underestimated in severely malnourished patients

Protein 1.2 - 1.5g/kg/d (upto 2 g/kg/d)

Elderly 1.2-1.5 g/kg/d AKI 1-1.2 g/kg/d

Glutamine supplementation is controversial

Fat

In weight-losing patients with IR : increase fat:carb ratio

to increase energy density & decrease glycemic load

Fat oxidation 0.7-1.9g/kg/d (upto 60-80% of REE)Arends J et al. Clinical Nutrition 2016. Article in Press

ESPEN guidelines on Nutrition in Cancer Patients

Carbohydrate (unknown carb-fat ratio)

Avoid hyperglycemia (IR)

Avoid hypoglycemia in advance liver metastasis

Vitamin & mineral : RDA

Avoid the use of high dose micronutrients in the

absence of specific deficiency

Dietary advice, ONS, EN, PN as indicated

Prevent refeeding syndromes

Clinical Nutrition 2016. Article in Press

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Thank you for your attention

Documents

Nutrition in Special Conditionsreviews.berlinpharm.com/20170311/Nutrition_in_Special_Conditions.pdf · 3/11/2017 · Nutrition in Special Conditions Prapimporn Ch. Shantavasinkul