Advanced Clinical Nutrition - University of Alberta

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Advanced Clinical Nutrition: AFNS 578

Department of Agricultural, Food and Nutritional Science, University of Alberta

Winter 2011

Dr. Diana Mager PhD RD

Course Description

*3 (3-0-3). The principles of clinical nutrition and the role of diet in the treatment and management of chronic disease. Emphasis will be on case studies and application of principles of advanced clinical nutrition for development of individualized nutritional care plans for clients with chronic disease.

Prerequisite NUTR 468. Pre- or corequisite: NUTR 302.

B. Objectives

This course will provide the students the opportunity to acquire knowledge and apply knowledge:

1) The role of nutrition in the prevention and treatment of selected diseases, nutritional disorders and clinical conditions

2) Assess, discuss and resolve clinical nutrition management problems. This will include the integration of knowledge and skills acquired from previous course work (nutrition,

biochemistry, physiology and behavioral science).

3) The role of the clinical dietitian as a member of the health care team in the provision of nutritional care.

C. Format:

Lectures Mon: 12-12:50; Wed 12-13:50) Lab/seminar: 3 hours/week; Wed 5-7:50 pm Location: CEB 331

D. Instructor (Office hours: M 1-2) Teaching Assistant(s)

Diana Mager PhD RD Stephanie Schwindt BaSc MSc candidate

3-18A Ag/Forestry Building Office Hours: Wed: 4-5

Phone: 492-7687 email:[email protected]

Email: [email protected]

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Week: Tentative Lecture Schedule Lab

January 10-14 Enteral Nutrition: Adjunctive vs Treatment Reading 1-6

Case: Crohn’s Disease Lab: Enteral feeding/tube

Surgical vs Medical Therapy devices/feeding pump/

Product tasting: SS

January 17-21 TPN: How & when to order Readings 6, 7-11

Biochemical, Anthropometric and clinical Lab:Enteral Calculation I

Assessment TA: SS

Complications of TPN: liver disease, sepsis, Overfeeding Case: Surgical Patient

January 24-28 Hypermetabolism Lab: TPN calculations I

Trauma/Sepsis/ICU TPN solutions

Case: Head injured patient Readings 12-15

Lab Monitoring TA: SS

Stanley Case January 31-Feb4 Hypermetabolism:Pulmonary/Disease/

ARDS: Michelle Booth Readings 16-20 Re-feeding syndrome/Cancer DM Lab: Enteral/TPN

Case: Cancer calculations TA: SS

Assignment 1 Due: Feb 2 2011 (20%).

M Booth Monday Jan 31, 2011 Lecture

Feb 7-11 Hypermetabolism: Transplantation Readings 21-23 Liver, bone marrow, and small intestine, pancreas Midterm

Graft vs Host disease SS/DM

Case: Liver & Small Intestine

Mid-term exam Feb 9, 2011 in seminar slot

Feb 14-18 Hypermetabolism: Burns Lab: TBA

ICU: Cardiac Disease/ Chylothorax Readings:24-25

Case: Burns TA: SS

Feb 21-25 Reading Week- No classes scheduled

Feb 28-March4 Renal Disease: Role of the kidney Readings 26-30 Chronic Renal Failure/Renal Insufficiency Lab: Renal Diets I

Dialysis (TT) TA: SS

March 7-11 Renal Disease II : Renal Transplantation Lab: Renal Diets II.

Cases: CRF/transplantation (TT) TA: SS/MF No lecture March 7, 2011 due to student union elections March 9: Dialysis Melanie Fougiere: 5-7

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March 14-18 Pediatrics: Inborn Errors of Metabolism Readings 31-32

Case(s): PKU/Tryosinemia/MSUD/ Lab: Metabolic Disorders /galactosemia-March 16 guest speaker TBA

Assignment 2 Due Wed March 16, 2011 (20%)

March 21-25 Pediatric Nutrition Assessment Readings 33-37

Full term vs prematurity Lab: Pediatric Assessment

Use of TPN vs Enteral DM

Failure to Thrive (FTT) Case: Hypermetabolism

March 28-April 1 Developmental Disabilities Lab: Dysphagia Energy Metabolism: Hypo-vs- Hypermetabolism Clinical Assessment

Dysphagia, Reading 34-36

Gastroesophageal reflux disease (GERD) SLP/RD guests

Case: GERD and Dysphagia; IHEP Stanley Home Care

April 4-8 Food Allergies & Hypersensitivities. Readings 38-39 IgEvs non IgE mediated intolerances IHEP: Charting Case: Milk/Protein Soy Allergies with NCP Lab: TBA

April 11-13 Geriatrics, Chronic Wounds Readings: 40-44

Tube feeding, Dysphagia Lab: Review/TBA

Case: Chronic Wounds

Assignment 3 Due on April 13

E. Evaluation Date

Mid-term Exam: 25% February 9, 2011

Term Assignments: 40% 3 assignments (15% , 15% and 10%).

Final Exam: 35% April 26 2011

Note: Final exam will be cumulative. The University grading system will be applied dependent upon the distribution of the final grades in the class and then absolute values will be attributed to the letter designations.

F. The lab/seminar section of the course may include the need for supplemental lecture material from course instructor Dr. Diana Mager. Some lab/seminars conducted by Dr. Mager/rest by TAs. The seminars will include hands-on experiential learning, videos, calculations and cased based learning in addition to didactic approaches. One in lab assignment March 24, 2010 worth 5% will be done in the actual seminar time (and handed it at the end of the seminar).

G. Past evaluative Material: Representative course evaluation materials from previous years will be posted on Web-CT approximately one week before the mid-term and one week before the final exam.

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H. Reference Materials Required Readings*

1. **Jeejeebhoy, KN. Enteral Feeding. Current Opin Gastroenterology 2004;20:110-113

2. McClave S, Neff R. Care and long term maintenance of percutaneous endoscopic gastrostomy tubes. JPEN 2006;30:S27.

http://pen.sagepub.com.login.ezproxy.library.ualberta.ca/content/30/1_suppl/S27.full

3. Bankhead R et al. ASPEN Enteral nutrition practice recommendations. JPEN 2009. Pages 131- 158; 162-167.

http://pen.sagepub.com.login.ezproxy.library.ualberta.ca/content/33/2/122.full.pdf+html 4. Chen, Y and Peterson SJ. Enteral Formulas: Which one is right for your adult patient. Nutr Clin

Prac 2009; 24; 344

http://ncp.sagepub.com.login.ezproxy.library.ualberta.ca/content/24/3/344.full

5. Andrew Ukleja, Kevin L. Freeman, Karen Gilbert, Marty Kochevar, Michael D. Kraft, Mary K.

Russell, Melanie H. Shuster. Standards for Nutrition support: adult hospitalized patients. Nutr Clin Pract 2010 25:403-414.

6. Andrew Ukleja. Altered GI Motility in Critically Ill Patients : Current Understanding of Pathophysiology, Clinical Impact and Diagnostic Approach. Nutr Clin Pract 2010 25: 16-25.

7. Gura K. Is there still a role for peripheral total parenteral nutrition. Nutr Clin Prac 2009:709-717.

8. Shenkin A, Biochemical Monitoring of Nutrition Support. Ann Clin Biochem 2006;269-272.

http://acb.rsmjournals.com.login.ezproxy.library.ualberta.ca/cgi/reprint/43/4/269

9. **Gidden, F, Shenkin A. Laboratory Support of the Clinical Nutrition Service. Clin Chem Lab Med 2000;38(8): 693-714.

10. Kumpf, VJ. Parenteral Nutrition-Associated Liver Disease in Adult and pediatric patients.

Nutrition in Clinical Practice 2006;21:279-290.

11. Stephen Marc Stout and M. Petrea Cober. Metabolic Effects of Cyclic Parenteral Nutrition Infusion in Adults and Children Nutr Clin Pract 2010 25: 277-281.

12. Todd SR, Kozar RA, Moore FA. Nutrition Support in adult trauma patients. Nutr in Clin Practice 2006;21:421-429.

13. Boitano M. Hypocaloric feeding of the critically ill. Nutr in Clin Practice 2006;21:617-622.

14. Frankenfield D. Energy expenditure and protein requirements after trauma injury. Nutr Clin Practice 2006;21:430-437.

15. Stephen A. McClave, Robert G. Martindale, Vincent W. Vanek, Mary McCarthy, Pamela Roberts, Beth Taylor, Juan B. Ochoa, Lena Napolitano, Gail Cresci, the A.S.P.E.N. Board of Directors and the American College of Critical Care Guidelines for the Provision and

Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient:: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) JPEN J Parenter Enteral Nutr 2009; 33; 277

http://pen.sagepub.com.login.ezproxy.library.ualberta.ca/content/33/3/277.full

16. Anker, SD, John M et al., ESPEN guidelines on enteral nutrition: cardiology and pulmonology.

Clin Nutrition 2006; 25:311-318.

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17. Malone, A. M. Specialized enteral formulas in acute and chronic pulmonary disease. Nutr Clin Practice 2009:24:666-674.

18. Esper DH, Harb WA. The cancer cachexia syndrome: a review of metabolic and clinical manifestations. Nutr Clin Practice 2005;20:369-376.

19. Kraft MD, Btaiche I, Sacks GS. Review of the refeeding syndrome. Nutr Clin Practice 2005;20:625-633.

20. Raykher A, et al. Enteral Nutrition Support of Head and Neck Cancer Patients. Nutr Clin Prac 2007;22:68-73.

21. Weimann A, Braga M, et al. ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation. Clin Nutr 2006;25:224-244.

22. Jeejeeboy KN. Short bowel syndrome: a nutritional and medical approach. CMAJ 2002;166(10):1297-1302.

http://www.ncbi.nlm.nih.gov.login.ezproxy.library.ualberta.ca/pmc/articles/PMC111082/

23. Nightingale, J, Woodward JM. Guidelines for management of patients with a short bowel. Gut 2006;55:1-12.

http://www.ncbi.nlm.nih.gov.login.ezproxy.library.ualberta.ca/pmc/articles/PMC2806687/pdf/IV 1.pdf

24. Lee JO. Benjamin D, Herndon, DN. Nutrition Support strategies for severely burned patients.

Nutr Clin Practice 2005;20:325-330.

25. Prelack, K, Dylewski, M, Sheridan RL. Practical guidelines for nutritional management of burn injury and recovery. J Burns 2006;2391

26. Kent PS. Integrating clinical nutrition practice guidelines in chronic kidney disease. Nutr in Clin Practice 2005;20:213-217.

27. Moore E. Celano J. Challenges of providing nutrition support in the outpatient dialysis setting.

Nutr in Clin Practice 2005;20:202-212.

28. Wooley JA, Btaiche I, Good KL. Metabolic and nutritional aspects of acute renal failure in critically ill patients requiring continuous renal replacement therapy. Nutr in Clin Practice 2005;20:176-191.

29. **Legg, V. Complications of Chronic Kidney Disease: A close look at renal osteodystrophy, nutritional disturbances and inflammation. AJN 2005:105:40-49.

30. Phil Ayers and Laurie Warrington, Diagnosis and Treatment of Simple Acid-Base Disorders.

Nutr Clin Prac 2008:23:122-127.

31. Nenad Blau, Francjan J van Spronsen, Harvey L Levy Phenylketonuria. Lancet Vol 376 October 23, 2010 1417-1427.

32. Morton DJ, Strauss KA et al., Diagnosis and treatment of maple syrup disease; a study of 36 patients. Pediatrics 2002;109:999-1008.

http://web.ebscohost.com.login.ezproxy.library.ualberta.ca/ehost/pdfviewer/pdfviewer?hid=119

&sid=fc37ecd9-699b-4ff5-9bfd-f0147c40aa81%40sessionmgr113&vid=3

33. Axelrod D, Kazmerski K, Iyer K. Pediatric Enteral Nutrition. JPEN 2006;30:S1-S26.

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http://pen.sagepub.com.login.ezproxy.library.ualberta.ca/content/30/1_suppl/S21.full 34. Alan H. Silverman Interdisciplinary Care for Feeding Problems in Children Nutr Clin Pract

2010 25: 160

35. Johnson T, Sexton E. Managing children and adolescents on parenteral nutrition: challenges for the nutrition support team. Proceedings of Nutr Society 2006;65:217-221.

http://journals.cambridge.org.login.ezproxy.library.ualberta.ca/action/displayFulltext?type=1&pd ftype=1&fid=815180&jid=PNS&volumeId=65&issueId=&aid=815168

36. Mager D & Pencharz P.B. Nutritional Considerations in Children with Developmental Disabilities. In: An Introduction to Developmental Disabilities in Ontario. Editor Front Porch Publishing, Toronto, Baltimore: Paul H Brookes Publishing Inc. Ontario 2007 (2^nd Edition).

37. Mascharenas M.R et al. Outpatient nutrition management of the neurologically impaired child.

Nutr Clin Prac 2008:23: 597-607.

38. Crary Ma, Groher M.E. Reinstituting Oral Feeding in Tube-Fed Adult Patients With Dysphagia.

Nutr Clin Prac 2006;21:576-586.

39. Garcia-Careaga M, Kerner JA. Gastrointestinal manifestations of food allergies in pediatric patients. Nut in Clin Practice 2005;20:526-535.

40. Chernoff R. Tube feeding patients with dementia Nutr in Clin Practice 2006;21:142-146.

41. Volkert D, et al. ESPEN guidelines on enteral nutrition: geriatrics. Clin Nutrition 2006;25:330- 360.

42. Jennifer Doley Nutrition Management of Pressure Ulcers Nutr Clin Pract 2010 25: 50-60.

43. Joyce K. Stechmiller Understanding the Role of Nutrition and Wound Healing Nutr Clin Pract 2010 25: 61-68.

*Note all readings are available through the U of A library electronic access via the following link. You can access this link through your University of Alberta ccid and password.

http://www.library.ualberta.ca/ejournals/search/index.cfm

Additional Readings (optional). These may or maynot be available via your University of Alberta electronic journal links.

1. The use of growth charts for assessing and monitoring growth in Canadian infants and children.

Can J Diet Prac 2004; 65:22-32.

2. Nutrition for Healthy Term Infants - Statement of the Joint Working Group: Canadian Paediatric Society, Dietitians of Canada and Health Canada;

3. Laubereau B, Brockow I, et al. Effect of breast feeding on the development of atopic dermatitis during the first 3 years of life-results from the Gini-Birth Cohort Study. J Pediat 2003;144:602- 607.

4. von Berg, A et al. Preventative effect of hydrolyzed infant formulas persists until age 6 years:

Long term results from the German Infant Nutritional Intervention (GINI) Study. J Allergy Clin Immunol 2008:121: 1442-1447.

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5. Christie L, Hine J, Parker JG, Burks W. Food allergies in children affect nutrient intake and growth. J Am Diet Associ 2002; 102:1648-1651

6. Marshall WJ. Nutrition assessment: its role in nutrition support. J Clin Pathol 2008; 61:1083-1088.

7. American Society for Parenteral and Enteral Nutrition: The Science and Practice of Nutrition Support-A Case Based Core Curriculum; 2006.

8. Modern Nutrition in Health and Disease, 10^th Edition. Lippincott Williams & Wilkins, 2006.

9. American Dietetic Association. Manual of Clinical Dietetics, 6^th Edition, Chicago: American Dietetic Association, 2000. www.dietitians.ca

10. A.S.P.E.N. Ethics Position Paper Task Force, Albert Barrocas, Cynthia Geppert, Sharon M.

Durfee, Julie O'Sullivan Maillet Cheryl Monturo, Charles Mueller, Kathleen Stratton, Christina Valentine and A.S.P.E.N. Board of Directors Nutr Clin Pract 2010 25: 672

11. Ellinger S et al. Efficacy of vitamin supplementation in situations with wound healing disorders:

results from clinical intervention studies. Curr Opin Clin Nutr Metab Care 2009:12:588–595 12. Morag J. Andrew and Peter B. Sullivan Growth in Cerebral Palsy Nutr Clin Pract 2010 25: 357-

361.

13. Lochs, H, Dejon C. et al. ESPEN Guidelines on Enteral Nutrition : Gastroenterology. Clin Nutrition 2006;25:260-274.

14. Mitch WE, Maroni BJ. Factors causing malnutrition in patients with chronic uremia. Am J Kid Dis 1999:33:176-179.

15. Wooley JA, Btaiche I, Good KL. Metabolic and nutritional aspects of acute renal failure in critically ill patients requiring continuous renal replacement therapy. Nutr in Clin Practice 2005;20:176-191.

16. Rex O. Brown, Charlene Compher and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of A.S.P.E.N. Clinical Guidelines : Nutrition Support in Adult Acute and Chronic Renal Failure JPEN J Parenter Enteral Nutr 2010 34: 366

17. Nutrition Care Process Update: Part 1 JADA; 2008;108(7):1113-1117.

18. Nutrition Care Process Update: Part 2 JADA; 2008;108(8):1287-1293

I. Additional Information

1. Electronic Devices: Electronic devices during examinations are restricted. Only approved non- programmable calculators will be allowed. Please consult me regarding this issue PRIOR to any mid-term or final exam to avoid any problems with this during the exam. Programmable calculators are NOT allowed. Taping of lectures/lab-seminar cannot be done without prior permission of the TAs and the instructor. Permission must be obtained before each session. Calculators should be brought to all lectures and seminars as there are hands-on calculations that need to be performed.

2. Late assignment: Late assignments will be accepted, however a deduction of 10% per day late will be applied. For example, if an assignment is due on Monday at 4:00 pm, and it is received any time after that, up until 4 pm the next day, 10% will be deducted from the total mark. If it is late a second day, an additional 10% will be deducted and so on. If an assignment is worth 30% or 30 marks then a deduction of 10% is worth 3 marks. Only hard copies of assignments will be accepted. No faxed or email assignments.

3. Academic Integrity: Code of Student Behavior

“The University of Alberta is committed to the highest standards of academic integrity and honesty.

Students are expected to be familiar with these standards regarding academic honesty and to uphold the policies of the University in this respect. Students are particularly urged to familiarize themselves with the provisions of the Code of Student Behaviour (www.ualberta.ca/secretariat/appeals.htm) and

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avoid any behaviour which could potentially result in suspicions of cheating, plagiarism,

misrepresentation of facts and/or participation in an offence. Academic dishonesty is a serious offence and can result in suspension or expulsion from the University.” (GFC 2003)

Code of Student Behaviour

“All students at the University of Alberta are subject to the Code of Student Behaviour, as outlined at http://www.ualberta.ca/~unisecr/policy/sec30.html and on pages 652-672 on the 2005-2006 Calendar.

Please familiarize yourself with it and ensure that you do not participate in any inappropriate behavior as defined by the Code. Key components of the code include the following statements.

30.3.2(1) Plagiarism: No Student shall submit the words, ideas, images or data of another person as the Student’s own in any academic writing, essay, thesis, project, assignment, presentation or poster in a course or program of study.

30.3.2(2) c. No Student shall represent another’s substantial editorial or compositional assistance on an assignment as the Student’s own work.”

Please speak to me if you have any questions or concerns about the Code, particularly as it pertains to team/group assignments, internet research using the same work as part of the assignments in more than one course, lab work and the definition of Plagiarism.

Policy about course outlines can be found in section 23.4(2) of the University Calendar (GFC 29 Sept 2004).