Module Catalogue List of Modules - lllnutrition.comlllnutrition.com/old/Old files 2017/ModuleCatalogue2008_old2.pdf · Module Catalogue Short description of modules to be developed

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Module Catalogue

Short description of modules to be developed in the LLL system: learning objectives, content and keymessages.

List of ModulesList of Topics and Modules to be Developed in the LLL System

Code Title Credits forLive course

Credits foron-line course

Topic 0 Introduction in Nutrition 3

Topic 1 Metabolism of Macro- and Micronutrients 3

EDU T1 M 1.1 Metabolism of Carbohydrates 1

EDU T1 M 1.2 Metabolism of Amino Acids and Proteins 1

EDU T1 M 1.3 Metabolism of Lipids 1

EDU T1 M 1.4 Prebiotics in Nutrition 1

EDU T1 M 1.5 Probiotics in Nutrition 1

EDU T1 M 1.6 Fibre in Nutrition 1

EDU T1 M 1.7 Metabolism of Phytochemicals 1

Topic 2 Water and Electrolytes in Health and Disease 3

EDU T2 M 2.1 Water and Electrolytes in Health and Disease 1

EDU T2 M 2.2 Metabolism of Vitamins 1

EDU T2 M 2.3 Metabolism of Minerals and Trace Elements 1

EDU T2 M 2.4 Metabolism of Antioxidants 1

Topic 3 Nutritional Assessment and Techniques 3

EDU T3 M 3.1 Nutritional Screening and Assessment 1

EDU T3 M 3.2 Body Composition 1

EDU T3 M 3.3 Energy Balance 1

EDU T3 M 3.4 Nutritional Evaluation of Hospitalized Children 1

Topic 4 Nutritional Requirements for Health throughout Life Span 3

EDU T4 M 4.1 Nutritional Requirements in Neonates 1

EDU T4 M 4.2 Nutritional Requirements in Infancy, Childhood andAdolescence 1

EDU T4 M 4.3 Nutritional Requirements in Pregnancy and Lactation 1

EDU T4 M 4.4 Nutritional Requirements in Adults 1

EDU T4 M 4.5 Nutritional Requirements in Elderly 1

Topic 5 Malnutrition 3*

EDU T5 M 5.1 Undernutrition – Simple and Stress Starvation 1

EDU T5 M 5.1 Overnutrition 1

Topic 6 Nutritional Support in Severe Malnutrition 3

EDU T6 M 6.1 Nutritional Support in Severe Undernutrition 1

EDU T6 M 6.2 Nutritional Support in the Obese Child and Adolescent 1

EDU T6 M 6.3 Nutritional Support in ICU Obese Patients 1

EDU T6 M 6.4 Nutritional Support after Bariatric Surgery 1

Topic 7 Enteral/Parenteral Nutrition - Substrates 3*

EDU T7 M 7.1 Substrates for Enteral and Parenteral Nutrition in Traumaand Septic Patients 1

EDU T7 M 7.2 Immunonutrition in Enteral and Parenteral Nutrition 1

Copyright © 2008 by ESPEN

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Topic 8 Approach to Oral and Enteral Nutrition (EN) 3

EDU T8 M 8.1 Indications and Contraindications of Enteral Nutrition 1

EDU T8 M 8.2 Oral and Sip Feeding 1

EDU T8 M 8.3 Techniques of Enteral Nutrition 1

EDU T8 M 8.4 Formulae for Enteral Nutrition 1

EDU T8 M 8.5 Monitoring and Complications of Enteral Nutrition 1

Topic 9 Approach to Parenteral Nutrition (PN) 3

EDU T9 M 9.1 Indications and Contraindications for Parenteral Nutrition 1

EDU T9 M 9.2 Techniques of Parenteral Nutrition 1

EDU T9 M 9.3 Compounding, Drugs and Nutritional Admixtures in PN 1

EDU T9 M 9.4 Monitoring and Complications of Parenteral Nutrition 1

Topic 10 Nutritional Support in Pediatric Patients 3

EDU T10 M 10.1 Nutritional Support in ICU Pediatric Patients 1

EDU T10 M 10.2 Parenteral Nutrition in Pediatric Patients 1

EDU T10 M 10.3 Enteral Nutrition in Pediatric Patients 1

Topic 11 Organization of Nutritional Care. Ethic and Legal Aspects 3*

EDU T11 M 11.1 Organization of Nutritional Care 1

EDU T11 M 11.2 Ethical and Legal Aspects 1

Topic 12 Nutritional Support in Gastrointestinal Diseases 3

EDU T12 M 12.1 The Compromised Gut 1

EDU T12 M 12.2 Nutrition After Extensive Gut Resections (Short BowelSyndrome) 1

EDU T12 M 12.3 Nutritional Support in Gastrointestinal Fistulas 1

EDU T 12 M12.4 Nutritional Support in Inflammatory Bowel Diseases 1

EDU T12 M 12.5 Nutritional Support in Acute and Chronic Diarrhoea 1

EDU T12 M 12.6 Nutrition in Prevention of Irritable Bowel Syndrome (IBS);Constipation and Diverticulosis 1

Topic 13 Nutritional Support in Liver Disease 3*

EDU T13 M 13.1 Nutritional Support in Acute Liver Disease 1

EDU T13 M 13.2 Nutritional Support in Chronic Liver Disease 1

Topic 14 Nutritional Support in Pancreatic Disease 3*

EDU T14 M 14.1 Nutritional Support in Acute Pancreatitis 1

EDU T14 M 14.2 Nutritional Support in Chronic Pancreatitis 1

Topic 15 Nutritional Support in Renal Diseases 3

EDU T15 M 15.1 Acute Renal Failure 1

EDU T15 M 15.2 Nutritional Support in Chronic Renal Failure 1

EDU T15 M 15.3 Nutritional Support in Hemodialysis (HP) Patients 1

EDU T15 M 15.4 Nutritional Support in Peritoneal Dialysis Patients 1

Topic 16 Nutritional Support in Injury and Sepsis 3

EDU T16 M 16.1 Metabolic Changes in Injury and Sepsis 1

EDU T16 M 16.2 Nutritional Support in Sepsis 1

EDU T16 M 16.3 Nutritional Support in Trauma 1

EDU T16 M 16.4 Nutritional Support in Burns 1

Topic 17 Nutritional Support in the Perioperative Period 3

EDU T17 M 17.1 The Stress Response and its Effects on Metabolism 1

EDU T17 M 17.2 Insulin Resistance and Glucose Control 1

EDU T17 M 17.3 Nutritional Support in the Perioperative Period 1

EDU T17 M 17.4 Nutritional Goals in the Perioperative Period 1

EDU T17 M 17.5 The Traumatized Patient 1


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EDU T17 M 17.6 Facilitating Oral or Enteral Nutrition in the PostoperativePeriod 1

Topic 18 Nutritional Support in Intensive Care Unit (ICU) Patients 3

EDU T18 M 18.1 Metabolic Response to Stress, Energy Requirements 1

EDU T18 M 18.2 Use of Macronutrients in ICU 1

EDU T18 M 18.3 General Principles of Prescription and Management 1

EDU T18 M 18.4 Routes of Nutrition in ICU 1

EDU T18 M 18.5 Use of Special Substrates in ICU 1

Topic 19 Nutritional Support outside the Hospital: Home Parenteral Nutrition(HPN) in Adult Patients 3

EDU T19 M 19.1 Indications and Epidemiology 1

EDU T19 M 19.2 Training and Monitoring 1

EDU T19 M 19.3 Venous Access for Home Parenteral Nutrition 1

EDU T19 M 19.4 HPN in Cancer Patients 1

EDU T19 M 19.5 Guidelines for Home Parenteral Nutrition Support in ChronicIntestinal Failure 1

EDU T19 M 19.6 Metabolic Complications of Home Parenteral Nutrition inChronic Intestinal Failure 1

Topic 20 Nutritional Support in Cardio-Vascular Diseases (CVD) 3*

EDU T20 M 20.1 The Place of Nutrition in the Prevention of Cardio-VascularDisease 1

EDU T20 M 20.2 Nutritional Features of Patients with Chronic Heart Failure 1

Topic 21 Consequences of Diabetes on the Nutritional Status 3*

EDU T21 M 21.1 Diabetes and Nutritional Status 1

EDU T21 M 21.2 Nutritional Support in Diabetes Type I and Type II 1

Topic 22 Nutrition in Lipidemias 3*

EDU T22 M 22.1 Clinical Consequences of Dislipidemias 1

EDU T22 M 22.2 Nutritional Support in Dislipidemias 1

Topic 23 Nutrition in Obesity 3*

EDU T23 M 23.1 Nutrition in the Prevention of Obesity 1

Topic 24 Nutrition in Metabolic Syndrome 3

EDU T24 M 24.1 What is the Metabolic Syndrome? 1

EDU T24 M 24.2 Insulin Resistance: Identification and Consequences 1

EDU T24 M 24.3 Lifestyle Interventions in Metabolic Syndrome 1

EDU T24 M 24.4 Pharmacological Treatment 1

EDU T24 M 24.5 Molecular Aspects of Metabolic Syndrome 1

EDU T24 M 24.6 Frontiers in Metabolic Syndrome Research 1

Topic 25 Nutritional Support in Neurological Diseases 3

EDU T25 M 25.1 Nutritional and Metabolic Consequences of NeurologicalDiseases 1

EDU T25 M 25.2 Indication and Ethical Aspects of Nutritional Support inNeurological Diseases 1

EDU T25 M 25.3 Nutritional Support in Stroke 1

EDU T25 M 25.4 Nutritional Support in Chronic Neurological Diseases 1

Topic 26 Nutritional Support in Cancer 3

EDU T26 M 26.1 Molecular Mechanisms of Muscle Wasting in Cancer Cahexia 1

EDU T26 M 26.2 Cancer Anorexia 1

EDU T26 M 26.3 Benefits and Limitations of Conventional Nutritional Support(CNS) for Cancer Patients 1

EDU T26 M 26.4 Pharmacological and Multimodal Therapy for Cancer Cahexia 1

EDU T26 M 26.5 Nutrition in the Prevention of Cancer 1


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Topic 27 Nutritional Support in AIDS 3*

EDU T27 M 27.1 Principles of Nutritional Therapy in HIV/AIDS 1

Topic 28 Nutrition in Allergic Diseases 3*

EDU T28 M 28.1 Nutrition and Food Allergy 1

Topic 29 Nutrition in Hereditary Diseases 3

EDU T29 M 29.1 Nutrition in Phenylketonuria 1

EDU T29 M 29.2 Nutrition in Lactose Intolerance 1

EDU T29 M 29.3 Nutrition in Celiac Disease 1

EDU T29 M 29.4 Nutrition in Cystic Fibrosis Patients – Impact and Intervention 1

Topic 30 Nutrition in Skeletal and Joint Diseases 3*

EDU T30 M 30.1 Nutrition in Prevention of Osteoporosis 1

EDU T30 M 30.1 Nutrition in Prevention and Treatment of Arthritis 1

Topic 31 Nutrition in Behavioral Disorders 3

EDU T31 M 31.1 Nutrition in Anorexia Nervosa 1

EDU T31 M 31.2 Nutrition in Bulemia 1

EDU T31 M 31.3 Nutrition in Alcohol and Drug Abuse 1

Topic 32 Food Safety 3*

EDU T32 M 32.1 Food Safety. Exposure to Toxic Environment 1

Topic 33 Nutrition and Public Health 3*

EDU T33 M 33.1 Nutrition and Public Health 1

Topic 34 Nutrigenomics 3*

EDU T34 M 34.1 Nutrigenomics – New Research Approaches 1

EDU T34 M 34.2 From Nutrients To Genes: Response to Nutrients 1

Topic 35 Economics of Nutrition 3*

EDU T35 M 35.1 Cost Benefit in Clinical Nutrition 1

Topic 36 Nutrition in Elderly 3

EDU T36 M 36.1 Malnutrition in the Elderly: Epidemiology and Consequences 1

EDU T36 M 36.2 Pathophysiology – Sarcopenia 1

EDU T36 M 36.3 Nutritional Screening and Assessment – Oral Refeeding 1

EDU T36 M 36.4 Artificial Nutrition 1

Topic 37 Nutrition and Sports 3*

Topic 38 Nutrition in Pulmonary Diseases 3

EDU T36 M 38.1 Prevalence and Mechanism of Undernutrition in ChronicObstructive Pulmonary Disease (COPD) 1

EDU T36 M 38.2 Nutritional Support in Respiratory Disease 1

EDU T36 M 38.3 Nutritional Support in Chronic Respiratory Failure (HomeRespiratory Rehabilitation) 1

Topic 39 Nutrition Support Team 3*

Topic 40 Nutrition and Research 3*


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Topic 1 Metabolism of Macro- and Micronutrients

Module 1.1 Metabolism of Carbohydrates

Learning Objectives

· To know major pathways of glucose metabolism in humans;· To understand regulation of glucose metabolism in healthy subjects;· To know effect of stress hormones on glucose metabolism;· To be informed about alterations of glucose metabolism in sepsis and other illnesses.

Contents

1. Carbohydrate in normal metabolism2. Regulation of glucose metabolism3. Metabolic responses to (critical) illness

Key Messages

· Glucose metabolism is primarily regulated by the balance between anabolic (insulin) and catabolic(epinephrine, nor-epinephrine, glucagon, cortisol and growth hormone) hormones;

· FFA (free fatty acids) are an important regulator of glucose metabolism;· In fasting conditions FFA and catabolic hormones maintain glucose production and decrease

glucose utilization in the insulin sensitive tissues (muscle and adipose tissue);· In postprandial conditions, insulin stimulates glucose uptake, glucose oxidation and glucose

storage in muscle. It stimulates fat storage in adipose tissue by stimulating glucose uptake. Itinhibits glucose production;

· Physical stress, by increasing the secretion of catabolic hormones and FFA, causes insulinresistance and hyperglycaemia (the latter when increased insulin secretion can not compensatefor insulin resistance). In addition, inflammatory mediators (TNF, interleukin 6 and others) aregenerally activated during critical illness and antagonize insulin’s actions (=induce also insulinresistance);

· Hyperglycaemia and insulin resistance may have deleterious effects on outcome in critical illness.

Module 1.2 Metabolism of Amino Acids and Proteins

Learning Objectives

· To know the basic routes of protein synthesis and degradation in cells;· To understand whole body protein synthesis and degradation during acute and chronic disease

states.

Contents

1. Introduction2. How proteins are synthesized3. How proteins are broken down4. How to measure whole body protein synthesis and breakdown5. Principle of ~UVbRa measurement6. How to measure organ protein synthesis and breakdown7. Which processes affect whole body protein synthesis and/or breakdown8. Nutrition


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8.1 Acute and prolonged starvation8.2 Aging8.3 Exercise8.4 Acute disease8.5 Chronic disease

Key Messages

· Proteins play a crucial role in biological processes and are continuously synthesized and brokendown by different routes;

· Whole body protein synthesis and breakdown are each the net result of protein synthesis andbreakdown in various organs;

· On a whole body level, protein synthesis and breakdown are measured with the use of amino acidisotopes;

· Although, in health, adults remain in zero protein balance, synthesis and breakdown aredifferentially affected by the stages of disease and prevailing conditions, e.g. starvation, feeding,sepsis, growth, convalescence, activity, etc., resulting in either net catabolism or anabolism.

Module 1.3 Metabolism of Lipids

Learning Objectives

· To characterize principal pathways of lipid metabolism;· To know the regulatory mechanism of lipid metabolism;· To be familiar with basic changes in lipid metabolism during a critical illness.

Contents

1. Basic pathways in lipid metabolism2. Lipid digestion and absorption3. Lipid metabolism in fasting conditions4. Influence of surgical stress, sepsis and organ failure

Key Messages

· Lipids are not only very important energy substrates but some fatty acids and lipid-solublevitamins act as metabolic regulators. After ingestion of a mixed meal, fat is preferentially storedin adipose tissue whereas carbohydrates are oxidized;

· During fasting, fatty acids are released from adipose tissue and utilized as energy substrate in liverand extra hepatic tissue. This process is effectively controlled by catecholamines and insulin,which regulate hormone sensitive lipase and lipoprotein lipase;

· During a critical illness, increased adipose tissue lipolysis together with decreased fatty acidoxidation leads to increased triglyceride production and deposition in the liver (and in othertissues), with an augmented production of VLDL. This situation may contribute to the aggravationof organ dysfunction. In addition, several major changes are observed with respect to theconcentration and composition of plasma cholesterol-rich lipoproteins.

Module 1.4 Prebiotics in Nutrition

Learning Objectives

· To identify the different physiological and chemical properties of prebiotics;· To explain the different effects of prebiotics.


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Contents

1. Effects of prebiotics2. Nutritional sources of prebiotics

Key Messages

· Regular fibre intake is essential for the general health and a normal bowel function;· Diets containing fermentable fibre as a source of short chain fatty acids (SCFA's) play a

fundamental role in maintaining gut mucosal function by avoiding epithelial atrophy and possiblybacterial and toxin translocation from the gut lumen into the circulation and also may reduce theincidence of systemic infections and diarrhoea in tube-fed patients.

Module 1.5 Probiotics in Nutrition

Learning Objectives

· To identify the different physiological and chemical properties of probiotics;· To explain the different effects of probiotics.

Contents

1. Effects of probiotics2. Nutritional sources of probiotics

Key Messages


fundamental role in maintaining gut mucosal function by avoiding epithelial atrophy and possiblybacterial and toxin translocation from the gut lumen into the circulation and also may reduce theincidence of systemic infections and diarrhoea in tube-fed patients.

Module 1.6 Fibre in Nutrition

Learning Objectives

· To identify the different physiological and chemical properties of fibre;· To explain the different effects of fibre in the gastrointestinal tract.

Contents

1. Classification of dietary fibres2. Effects of fibres in the gastrointestinal tract3. Nutritional sources of fibres

Key Messages


fundamental role in maintaining gut mucosal function by avoiding epithelial atrophy and possibly


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bacterial and toxin translocation from the gut lumen into the circulation and also may reduce theincidence of systemic infections and diarrhoea in tube-fed patients.

Module 1.7 Metabolism of Phytochemicals

Learning Objectives

· To identify the different physiological and chemical properties of phytochemicals;· To explain the different effects of photochemical;· Phytochemicals as the natural sources of vitamins, antioxidants and microelements.

Contents

1. Vegetables and Fruits1.1 Cruciferous Vegetables (broccoli, cabbage, Brussels sprouts, cauliflower)1.2 Leafy Greens (spinach, kale, parsley, collard)1.3 Tomatoes1.4 Carrots1.5 Beets1.6 Grapes1.7 Soybeans1.8 Grape seeds1.9 Sunflower seeds

2. Herbs2.1 Garlic2.2 Green Tea2.3 Milk Thistle2.4 Bilberry2.5 Astragalus2.6 Aloe2.7 Schisandra2.8 Siberian ginseng2.9 Turmeric2.10 Curcumin2.11 Ginko Biloba2.12 Ginger2.13 Cayenne pepper

Key Messages

· Which phytochemicals possess true disease-preventing and/or health-promoting properties andtherapeutical potentials?

· Once identified, what are the dose limits in order to avoid risks to health?· Are potential side effects likely to emerge following high intakes of nutritive and non-nutritive

phytochemicals?· Are phytochemicals to be considered as future intravenous components the green parenteral?


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Topic 2 Water and Electrolytes in Health and Disease

Module 2.1 Water and Electrolytes in Health and Disease

Learning Objectives

· To understand basic concepts in water and electrolyte metabolism;· To be aware of the influence of trauma and sepsis on fluid and electrolyte physiology - to

understand the consequences and treatment of extra renal losses of water.

Contents

1. Introduction2. Water and fluid compartments3. Flux of fluid through the gastrointestinal tract4. Role of the kidney5. External fluid balance6. Effects of starvation and injury7. Electrolytes8. Sodium9. Potassium10. Magnesium11. Phosphate12. Calcium

Key Messages

· Fluid balance should be considered in terms not only of external loss or gain but also of theintercompartmental shifts, which occur with disease;

· Injury and starvation are associated with retention of salt and water and expansion of ECF;· The ability to excrete an excess salt and water load returns during convalescence. Potassium,

phosphate and Mg are lost during catabolic illness and require replacement during the anabolicconvalescent phase;

· A proper understanding of normal and abnormal fluid and electrolyte physiology is necessary inthe proper management of patients receiving nutritional support.

Module 2.2 Metabolism of Vitamins

Learning Objectives

· To understand the physiological roles of vitamins;· To know the effects of deficiency;· To know the methods of measurements and their limitations.

Contents

1. Thiamine (vitamin B1)2. Riboflavin (vitamin B2)3. Niacin (vitamin B3)4. Pyridoxal (vitamin B6)5. Folate (vitamin B9)6. Vitamin B12


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7. Vitamin C8. Biotin9. Vitamin A10. Vitamin D11. Vitamin E12. Vitamin K13. Vitamins - summary of influence of metabolic stress14. Assessment of vitamin status in clinical practice

Key Messages

· Vitamins are essential organic micronutrients, which are required in the diet in relatively smallamounts;

· However, they are necessary for both healthy and diseased organism;· Deficiency states of vitamins – avitaminosis leads to impairing certain important functions.

Module 2.3 Metabolism of Minerals and Trace Elements

Learning Objectives

· To understand the normal roles of minerals and trace elements;· To know the effects of deficiency or excess;· To know the methods of measurements and their limitations.

Contents

1. Zinc2. Copper3. Iron4. Selenium5. Chromium6. Molybdenum7. Manganese

Key Messages

· Trace elements are essential inorganic micronutrients, which are required in the diet in very smallamounts;

· In spite that only small amounts are necessary they are critical for both health and disease;· The deficiency of certain trace elements leads to impairing important functions.

Module 2.4 Metabolism of Antioxidants

Learning Objectives

· To know the basic sources of free radicals in human body;· To explain basics of antioxidant defence system;· To list some conditions leading to oxidative stress;· To characterize ischemia/reperfusion (I/R) injury.

Contents

1. Definitions


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2. What is a free radical?3. What is antioxidant capacity?4. What is oxidative stress?5. Antioxidative therapy - facts and fancy6. Ischemia/reperfusion injury7. Some major questions related to antioxidation therapy, yet to be answered, are:

Key Messages

· Antioxidants are important compounds to protect cells and tissues from oxidative and nitrosicstress. It has been becoming more and more clear that the major antioxidants, vitamins E, C andGSH may act in a synergistic or complementary fashion;

· Ascorbate scavenges a wide variety of oxidants, including myeloperoxidase-derived hypochlorite,and regenerates vitamin E;

· A network of antioxidants for defence against oxidative stress may have the benefit of functionaloverlap, which will ensure that any individual component will be available in sufficient amounts ondemand. Thus, it may be more beneficial to provide the patients with an >>antioxidant cocktail.We propose tentative proportions of supplementary vitamin E, C and b-carotene as 1:2:0.1;

· The present accumulated knowledge about antioxidants undoubtedly represents a great challengefor physicians, nutritional scientists, pharmacists, food technologists and food chemists. Theincreasing number of investigations in this field will presumably raise more questions as well assolutions;

· Hopefully, future success in putting acquired knowledge into practice will be rewarded byimproved patient survival. Continued rigorous critical evaluation of assumptions and hypothesesabout relationships between diet, nutrition, health and disease should provide us with reliableknowledge of what can and what cannot be achieved through clinical nutrition.

Topic 3 Nutritional Assessment and Techniques

Module 3.1 Nutritional Screening and Assessment

Learning Objectives

· To understand the difference between nutritional screening and assessment;· To be able to do nutritional screening;· To recognize the signs and symptoms of malnutrition;· To know how to choose and use nutritional questionnaires and to know the recommended

questionnaires by ESPEN;· To understand different methods for nutritional assessment;· To know the benefits and limitations of different methods and tools for nutritional assessment.

Contents

1. Nutritional screening and assessment2. Screening

2.1 Community: Malnutrition Screening Tool (MUST)2.2 Hospital: Nutritional Risk Screening (NRS)2.3 Elderly: Mini Nutritional Assessment (MNA)

3. Methods used in nutritional assessment3.1 History3.2 Physical examination and functional test3.3 Laboratory parameters

3.3.1 Serum proteins3.3.2 Electrolytes, urea and creatinine3.3.3 Vitamins and minerals


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3.3.4 Creatinine height index (CHI)3.3.5 Nitrogen balance studies3.3.6 Total lymphocyte counts (TLC) and delayed hypersensitivity reactivity (DHR)

4. Assessment of food intake and nutritional questionnaires

Key Messages

· Nutritional screening and assessment are important parts of patient care;· Nutritional screening and assessment identify patients at risk and those requiring nutritional

support;· Nutritional screening is a rapid and simple tool and should be done in every patient;· Nutritional assessment is important for detailed diagnosis of acute and chronic malnutrition;· Food intake should be evaluated in all patients at risk of malnutrition.

Module 3.2 Body Composition

Learning Objectives

· To learn how body composition can be measured and to learn how reliable these measurementsare;

· To learn why a normal body composition is necessary for health;· To learn what influences body composition;· To learn which components of body composition are essential for health.

Contents

1. Why is body composition important?2. The components of the body and their importance.3. Changes in body composition in starvation and disease/starvation.4. How to measure body composition?

4.1 Easy methods4.1.1 Anthropometry4.1.2 Functional tests4.1.3 Creatinine excretion rate4.1.4 Nitrogen balance4.1.5 Other tests4.1.6 Bioelectrical impedance spectroscopy (BI)

4.2 Sophisticated methods4.2.1 Dual energy X-ray absorptiometry (DEXA)4.2.2 Magnetic Resonance Imaging (MRI) and Computed Tomography (CT)4.2.3 Dilution methods4.2.4 Under water weighing4.2.5 Total body Potassium

Key Messages

· The integrity of body cell mass crucially determines health, including muscle function andhostresponse;

· Lack of uptakeor/en intake of nutrition and inflammatory activity decrease body cell mass;· Fat mass and fat free mass can be measured relatively easily;· In health fat free mass is linearly related to body cell mass;· In starvation and stress/starvation the ratio BCM/ECM decreases, which makes FFM a less reliable

indicator of nutritional state;· In vivo body composition measurements are always indirect, based on one or more assumptions

concerning the nature of the body components fat mass and fat-free mass;


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· The other methods are all double-indirect, validated against indirect methods, and thereforebased on more assumptions;

· Whatever method is used, the starting point is the measurement of body mass with a calibratedscale.

Module 3.3 Energy Balance

Learning Objectives

· To know the components of energy expenditure in human beings;· To understand the flow of energy in biosphere;· To understand the concept of energy intake and expenditure in humans;· To know the methods for measurement of energy expenditure;· To be able to define how energy intake influences energy expenditure.

Contents

1. Definition of energy expenditure2. Components of energy expenditure3. Methods for measurement of energy expenditure

3.1 Direct calorimetry3.2 Indirect calorimetry3.3 Estimation of energy expenditure

4. Influence of disease on energy expenditure5. Energy intake and energy balance

Key Messages

· Energy demanding processes in humans are covered by energy from foodstuff or body energyreserve stores of carbohydrates, fat and protein;

· Total energy expenditure consists from resting energy expenditure (REE), diet induced energyexpenditure (DEE), and energy spent for activity (AEE);

· Activity induced energy expenditure (AEE) - is the most variable part of energy expenditure;· Indirect calorimetry is the most exact method to measure energy expenditure;· REE is dependent mainly on fat-free body mass, but it is influences many factors such as disease or

inflammatory activity, hormonal status or drug treatment;· Positive energy balance is necessary condition for growth and development as well as for healing

processes and muscle gain during rehabilitation;· Positive energy balance is connected with development of obesity in an adult patient.

Module 3.4 Nutritional Evaluation of Hospitalized Children

Learning Objectives

· To be aware of how malnutrition presents and how to screen, assess, and monitor patients fornutritional risk and for response to nutritional support;

· To be aware of the importance of the routine screening all patients for malnutrition and of thecontinued monitoring of those at risk;

· To appreciate the value of such diagnostic methods combined with measures of growth anddevelopment to indicate the presence of underlying disease as well as guiding nutritionalmanagement;

· To appreciate the value and place of investigative methods such as DEXA, Biochemistry etc.;· To be aware of the value of an expert Nutrition Team in all major Paediatric centres.


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Contents

1. Introduction2. Goals of nutritional assessment

2.1 Confirmation of normal growth2.2 Detection of chronic disease2.3 Follow up of nutritional intervention or acute situations2.4 Analysis of acute situations

3. Evaluation of nutritional status4. Nutritional Risk Score

Key Messages

· The practical assessment of nutritional status must be based on a clinical approach associatedwith simple and reproducible methods for the assessment of growth and body composition;

· Analysis of growth (weight gain and growth velocity) using growth curves remains the simplest toolfor assessing changes in nutritional status in children;

· Biological assessment is designed for specific situations and is not part of systematic follow up;· Supplements of minerals, trace elements, and vitamins may be necessary in situations where

deficits are likely, on clinical grounds, but are not given routinely in most cases;· Among the new technologies, DEXA is one of the most useful for measuring bone density and body

composition;· Nutritional screening and assessment methods should not only be able to detect current

malnutrition but be able to give some prediction of future changes in nutritional risk, using anutritional risk score;

· Nutritional assessment allows nutritional support to be introduced in a timely fashion, therebyreducing morbidity and mortality, and limiting the long-term impact of malnutrition on growth anddevelopment.

Topic 4 Nutritional Requirements for Health throughout Life Span

Module 4.1 Nutritional Requirements in Neonates

Learning Objectives

· To understand the physiological differences, concerning growth and development that define thenutritional needs of the neonates;

· To understand the differences in the balance of energy, proteins, water, electrolytes, mineralsand micronutrients in different ages;

· To give generally accepted recommendations for all nutrients intake.

Contents

1. Premature / Low Birth Weight infants (LBWI)1.1 Energy1.2 Proteins1.3 Fats1.4 Carbohydrates1.5 Water1.6 Minerals1.7 Electrolytes1.8 Vitamins

2. Healthy term infants 0 – 12 months2.1 Energy2.2 Protein


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2.3 Electrolytes, minerals, vitamins

Key Messages

· Age definition of Premature and Low Birth Weight Infants (LBWI);· Physiological characteristics of Full-term and Premature/LBWI define their different nutritional

needs;· The needs of protein, energy and all other nutrients are much higher than in the adults;· Most part of the nutrients is used for cellular proliferation and less for physical activity;· Undernutrition;· In the neonates and especially low birth weight, undernutrition can easily cause physical and

mental retardation that may be irreversible.

Module 4.2 Nutrition in Infancy, Childhood and Adolescence

Learning Objectives

By the end of this module, the student should be able to:· Identify macronutrients and micronutrients important to paediatric nutrition;· Identify benefits of and contraindications to breastfeeding;· Distinguish which type of formula may be appropriate for a given patient;· Describe the timing and composition of complementary feeding;· Summarize feeding strategies from age 1 through adolescence.

Contents

1. Introduction2. Basic principles of paediatric nutrition

2.1. Reference Nutrient Intake2.2. Energy requirement2.3. Macronutrients2.4. Micronutrients, vitamins, and minerals.

3. Infant feeding3.1. Breastfeeding

4. Formula feeding4.1. Infant formulae and follow-on formulae4.2. Infant formulae based on protein hydrolysate4.3. Soy protein based formulae4.4. Probiotics4.5. Prebiotics4.6. Fermented infant formulae without live bacteria4.7. Long chain polyunsaturated fatty acids4.8. Nucleotides4.9. Preparation and handling of powdered infant formula

5. Complementary feeding5.1. Special considerations

6. Feeding of Children and Adolescents6.1. Feeding recommendations for toddlers6.2. Feeding recommendations for children aged 3 to 5 years6.3. Feeding recommendations for children aged 6 to 12 years6.4. Feeding recommendations for adolescents


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Key Messages

Breastfeeding· All infants should be exclusively breastfed from birth to about 6 months (26 weeks) of age or at

least for the first 4 months (18 weeks) of life;· Breastfeeding should preferably continue beyond the first year of life; in populations with high

rates of infection, continued breastfeeding throughout the second year and longer is likely tobenefit the infant.

Formulae feeding· Infants who cannot be breastfed, or should not receive breast milk, or for whom breast milk is not

available, require breast milk substitutes of high quality.

Complementary feeding• Complementary foods should be introduced at about 6 months of age. Some infants may need

complementary foods earlier but not before 4 months of age.• Complementary feeding should be a process of introducing foods with an increasing variety of

texture, flavour, aroma and appearance, while maintaining breastfeeding;• New foods should not be introduced too often – generally not more frequently than every 3 days –

nor should more than one new food be introduced at a time.

Feeding of preschool & school children and adolescents· Providing adequate energy and nutrients to ensure adequate growth and development remains the

most important consideration in the nutrition of children;· Small frequent feedings play a significant role in providing energy in the diets of children;· From the age of 2 years until the end of linear growth, there should be a transition from the high

fat diet of infancy to a diet that includes no more than 30% of energy as fat and no more than 10%of energy as saturated fat;

· Physical activity and healthy eating are important lifestyle habits for children.

Module 4.3 Nutritional Requirements in Pregnancy and Lactation

Learning Objectives

· To know the recommended diet allowances for pregnancy and lactation;· To be familiar with the nutritional assessment of the expectant mother;· To know the most common indications for nutritional support during pregnancy and lactation

complicated by starvation;· To know the risks of gain weight, anaemia, malnutrition, etc.;· To learn the rules of artificial nutrition during pregnancy and lactation complicated by starvation;· To recognize the adverse effects of starvation on pregnancy and foetal outcome.

Contents

1. Nutritional assessment of the expectant mother2. Physiologic changes and metabolic changes in pregnancy3. Essential of human lactation4. Recommended diet allowances for pregnancy and lactation5. Risk of pregnancy related complications6. Indications and aims of nutritional support

Key Messages

· Pregnancy constitutes a special situation, where adequate nutrition is vital for both mother andchild;

· The recommended diet allowances for pregnancy and lactation should be followed to avoid a riskof weight gain, anaemia, hypertension, malnutrition and other complications of pregnancy and


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lactation;· Special nutritional support should be implemented in case of pregnancy and lactation, particularly

for pregnancy with complications and starving or semistarving pregnant women;· Delay in giving nutritional support to starving or semistarving pregnant women adversely affects

the foetus and may result in increased foetal mortality and morbidity.

Module 4.4 Nutritional Requirements in Adults

Learning Objectives

· To learn how to estimate energy requirements of healthy adults;· To determine the macronutrient requirements at rest and during physical activity;· To learn which type of macronutrients are beneficial for health.

Contents

1. Energy requirements1.1 Carbohydrates

1.1.1 Glycaemic index (GI)1.2 Lipids

1.2.1 Saturated fatty1.2.2 Monounsaturated fatty1.2.3 Polyunsaturated fatty acids (PUFA)

1.3 Proteins1.4 Vitamins, Minerals and Electrolytes

Key Messages

· Total energy requirements vary from one individual to another;· Carbohydrate and fat requirements are set at 50-55% and 30-35%, respectively, of total energy

intake for healthy subjects at rest;· Protein allowances should be 0.8g/kg b.w;· Physical exercise increases energy requirements;· The macronutrient requirement of physically active subjects is similar to resting subjects although

an increased carbohydrate intake may be recommended;· During exercise lasting more than one hour, carbohydrate supplementation may help to delay

fatigue.

Module 4.5 Nutritional Requirements in Elderly

Learning Objectives

· To understand some of the relevant physiological changes of aging;· To understand the mechanism of malnutrition in the elderly;· To know the prevalence, causes and consequences of malnutrition in the elderly;· To be able to screen and assess elderly patients for malnutrition in the context of health and

disease;· To be able to manage and treat malnutrition in the elderly.

Contents

1. Introduction1.1 Malnutrition in the elderly and outcome


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1.2 Detection of malnutrition in the elderly1.3 Mini Nutritional Assessment (MNA)

2. Changes in body composition and function2.1 Energy balance2.2 Appetite in the elderly2.3 Small-bowel bacterial overgrowth in elderly people

3. Changes in nutrient requirements3.1 Total Energy3.2 Protein3.3 Fat3.4 Carbohydrates3.5 Fibre3.6 Fluids3.7 Vitamins3.8 Minerals3.9 Nutritional intervention3.10 Pressure sores

4. The ageing immune system5. Drug interactions in the elderly6. Nutrition in different conditions in the elderly

6.1 Osteopenia with ageing6.2 The aged diabetic6.3 Cardiovascular system and ageing6.4 Malnutrition and mental function in the elderly6.5 Cancer in the elderly

7. Ethical considerations

Key Messages

· The elderly as a group are particularly susceptible to malnutrition especially when suffering fromchronic mental or physical disease;

· Elderly patients should all be screened for risk of malnutrition and have an appropriate care plan.Where significant malnutrition exists there is clear evidence of benefit from nutrition support;

· There is suggestive evidence that good nutrition and even the use of vitamin and mineralsupplements may have an important preventive role in maintaining health and quality of life inthe elderly;

· In making any care plan, ethical considerations are important, respecting the patient's autonomy,ensuring benefit and avoiding harm.

Topic 5 Malnutrition

Module 5.1 Undernutrition – Simple and Stress Starvation

Learning Objectives

· To know how the body reacts to short-term and long-term starvation during non-stress conditions;· To understand the difference between simple and stress starvation;· To know the consequences of stress on metabolic pathways related to starvation.

Contents

1. Definition and classification of malnutrition2. Undernutrition3. Aetiology of undernutrition4. Adaptation to undernutrition – non stress starvation5. Stress starvation


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Key Messages

· Humans adapt well to short or longer-term starvation, using their reserves of carbohydrates, fatand protein.

· Reduction in energy expenditure and conservation of body protein are further adaptations tostarvation. Energy stores are replenished during the feeding period.

· Long-term partial or total cessation of energy intake leads to marasmic wasting.· With the addition of the stress response, catabolism and wasting are accelerated and the normal

adaptive responses to simple starvation are overridden.· Loss of weight and specifically loss of body cell mass in either situation results in impaired mental

and physical function, as well as in poorer clinical outcome.

Module 5.2 Overnutrition

Learning Objectives

· To explain the risk of chronic overfeeding;· To explain the nutritional and physiological role of adipose tissue;· To explain the relationship of obesity to metabolic syndrome X;· To summarize shortly the nutritional treatment of obese patients;· To understand problems of perioperative nutrition and risk of obese patients;· To learn basic nutritional approaches to bariatric surgery.

Contents

1. Physiology of adipose tissue2. Acute overfeeding3. Chronic overfeeding4. Risks of obesity5. Health6. Socio-economic7. Metabolic syndrome8. Treatment of obesity9. Bariatric surgery

Key Messages

· The main complication of chronic overnutrition is obesity, which is associated with seriouscomplications, e.g. diabetes, cardiovascular disease and cancer. These can be decreased bylosing 5-10% of weight, reducing insulin resistance, and the production of many atherogenic,pro-coagulatory, diabetogenic, hormonal and metabolically active substances;

· Even with such a small reduction in weight, adipose tissue is again capable of protecting organssuch as liver, pancreas and muscles from accumulation of fat. In catabolic illness, obese patientsare just as vulnerable to malnutrition and should be screened and given appropriate nutritionalsupport;

· The incidence of peri-operative complications is higher in the obese, but has been significantlyreduced by laparoscopic surgery;

· The risks of morbid obesity are high and can be significantly reduced by bariatric surgery;· Gastric banding cannot be successful without proper perioperative and postoperative nutritional

support and diet education.


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Topic 6 Nutritional Support in Severe Malnutrition

Module 6.1 Nutritional Support in Severe Undernutrition

Learning Objectives

· To characterize the metabolic situation in severely malnourished patient;· To know methods of nutritional support in severely malnourished patients;· To be aware of possible risks connected with nutritional support in severely malnourished patients.

Contents

1. Pathophysiology2. Goals of nutritional therapy3. Oral nutritional support4. Enteral nutrition5. Parenteral nutrition6. Monitoring7. Rehabilitation

Key Messages

· Lack of electrolytes and micronutrients should be supposed in severely malnourished subjects;· Supplementation of deficient electrolytes and vitamins is necessary during nutrition support of

severely malnourished persons;· The intake of macronutrients should be gradually increased in severely malnourished persons;· Severely malnourished patients need more K, P, Mg, Zn, and vitamins than well-nourished

subjects. Final energy and protein needs are also higher (up to 40–45 kcal/kg/day and1.5 g/kg/day, respectively) in order to accelerate repletion of deficits;

· The administration of standard formula for enteral nutrition may be supplemented withparenteral infusion of electrolytes, minerals and vitamins;

· The early goal of feeding is improved function and accelerated rehabilitation. Restoration oflean mass is a longer term objective over weeks and months.

Module 6.2 Nutritional Support in the Obese Child and Adolescent

Module 6.3 Nutritional Support in ICU Obese Patient

Learning Objectives

· To know how to estimate energy requirements in severely obese patient;· To be aware that nutrition support is integral part of treatment of critically ill obese patient;· To know the protein requirements of obese patient who requires nutritional support.

Contents

1. Characteristic of risks connected with severe obesity2. Complications connected with surgery and acute illness in severely obese patient3. Nutrition intake in severely obese patient

3.1 Energy intake3.2 Protein and amino acid intake

4. Monitoring of nutritional support in severely obese patient


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Key Messages

· Mobilization of energy reserves is impaired in critically ill and severely obese patient;· Critical situation leads to muscle wasting in normally nourished as well as in severely obese

patient. Muscle wasting n severely complicates weaning from ventilator, wound healing andincreases rate of complications;

· Energy intake in severely obese patient needs nutritional support which should be adjusted to hisor her adjusted body weight;

· Protein intake in critically ill obese patient is 1.5-2 g/kg ideal body weight per day.

Module 6.4 Nutritional Support after Bariatric Surgery

Topic 7 Enteral/Parenteral Nutrition – Substrates

Module 7.1 Substrates for Enteral and Parenteral Nutrition inTrauma and Septic Patients

Learning Objectives

· To explain the metabolic effects of very low or very high energy intake during nutritional support;· To characterize the energy needs during enteral and parenteral nutrition;· To distinguish the difference between energy needs in stable and critically ill patient.

Contents

1. Introduction2. Energy3. Macronutrients

3.1 Carbohyrdates3.2 Amino Acids3.3 Lipids

4. Micronutrients and Vitamins5. Water and Electrolytes6. Fibres for EN7. PN formulas and lipid emulsions8. Addition of special substrates

Key Messages

· Energy needs should be determined in relation to expenditure, but also to the ability of a patientto metabolize substrates correctly;

· Most hospitalized patients present a combination of stress and malnutrition. Their energyexpenditure is often lower than values obtained from classical equations and textbook tables. Thevast majority of patients, including those in ICU, have energy expenditures, which do not exceed2000 kcal/d;

· Aiming at achieving positive or zero nitrogen balance via hypercaloric support should bediscouraged during the acute metabolic phase of sepsis or trauma;

· Overfeeding during acute illness may be associated with major complications and side effects;· The target should consist of preserving function and limiting major depletion of lean body mass by

starting nutritional support at an early stage, but with limited amounts of energy substrates;


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· Hence, partial (under) feeding is acceptable during the hypermetabolic phase, while increasedenergy intakes may be useful in the recovery or anabolic phase of illness when tissue rebuilding ispossible.

Module 7.2 Immunonutrition in Enteral and Parenteral Nutrition

Learning Objectives

· To know the most important risk factors for the occurrence of postoperative infections;· To understand the limitations of preoperative artificial nutrition in improving postoperative

outcome;· To understand how immunonutrition modulates the postoperative inflammatory and immune

response;· To know the clinical impact of immunonutrition in both surgical and ICU patients;· To understand how cost-benefit analysis should be performed.

Contents

1. Postoperative inflammatory/immune responses2. Postoperative infections: risk factors3. Limitations of standard artificial nutrition in preventing postoperative infections in undernourished

patients4. Basic principles of immunonutrition and effects of specific substrates5. Postoperative immunonutrition: metabolic effects, outcome results, limitations to effectiveness of

postoperative feeding alone.6. Perioperative immunonutrition: metabolic effects, outcome results7. Cost-benefit analyses8. Immunonutrition in ICU patients

Key Messages

· The postoperative stress response is necessary to survival but can also have adverse consequenceswhich require therapeutic intervention. Balancing the opposing aspects of this paradox has alwaysbeen one of the challenges of clinical nutrition. Standard preoperative artificial nutrition reducespostoperative infections only in severely undernourished patients;

· Immunonutrition is able to modulate the postoperative inflammatory response and to reduceimmune system impairment after surgery;

· Immunonutrition reduces the postoperative infection rate when started before surgery, regardlessof baseline nutritional status;

· In elective surgical GI cancer patients immunonutrition is cost-effective;· In ICU patients without septic shock immunonutrition reduces neither mortality nor morbidity in

trauma patients;· In patients with septic shock immunonutrition increases mortality (post-hoc analyses).

Topic 8 Approach to Oral and Enteral Nutrition (EN)

Module 8.1 Indications and Contraindications of Enteral Nutrition

Learning Objectives

· To understand the main indications for EN;· To identify patients who might benefit from EN;· To know the main contraindications to EN.


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Contents

1. What exactly is EN?2. Indications for EN

2.1 Definition of malnutrition and nutritional risk2.2 Specific indications for EN according to the ESPEN guidelines 2006

3. Contraindications to EN

Key Messages

· EN is a safe and effective method of nutritional therapy;· Main indication for EN is prevention and treatment of malnutrition in order to improve outcome;· Main contraindications are severe impairment of gastrointestinal function and metabolic instability.

Module 8.2 Oral and Sip Feeding

Learning Objectives

· To be aware of the importance of optimal nutrition in hospital patients;· To know about the different menus and possibilities of fortification offered by the average hospital

food service;· To learn about innovative approaches to increase nutritional intake of normal food in hospital

patients;· To know the indications for and types of oral nutritional supplements.

Contents

1. Why is oral nutrition important in hospital patients?2. Requirements of oral nutrition in hospital3. Monitoring and improving oral intake4. Fortification of standard hospital food and oral supplements (sip feeds)5. When to administer oral supplements

Key Messages

· Oral feeding with either normal food or special and/or fortified diets is always the first choice toprevent or treat undernutrition in patients;

· Food served in hospitals should be a “role model” for food at home, i.e. should have a high qualityin terms of nutritional physiology, raw materials and preparation and should be attractive in tasteand appearance;

· The quantity of oral intake must be carefully monitored, especially in patients at nutritional risk;· Sip feeding (oral nutritional supplements) should be used when adequate oral intake of normal food

including special and/or fortified diets is not possible.

Module 8.3 Techniques of Enteral Nutrition

Learning Objectives

· To know about the different types of tubes and access routes;· To know when to use which type of tube and access route;


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· To understand the indications for the various feeding techniques (oral nutritional supplements,continuous versus bolus versus intermittent tube feeding, minimal enteral nutrition, early enteralfeeding);

· To know when and how to use starting regimens;· To know how to react in case of high gastral reflux.

Contents

1. Introduction2. Legal regulation3. Safety and quality standards

3.1 Feeding tubes and delivery systems3.2 Hygienic aspects of enteral feeding systems

4. Contraindications for enteral access5. Routes of enteral access

5.1 Nasogastric/nasoenteric tube5.2 Percutaneous endoscopic gastrostomy (PEG)5.3 Skin level gastrostomy (Button)5.4 Percutaneous endoscopic jejunostomy (PEG-J or D-PEJ)5.5 Surgical access

6. Management6.1 Bolus versus continuous feeding6.2 Approach to a feeding protocol

Key Messages

· If oral nutrition cannot be maintained artificial enteral nutrition may be indicated using a feedingtube;

· The material and construction of a feeding tube should result in a maximum of safety, comfort andfunctionality;

· Bacterial contamination of the enteral feeding system has to be avoided;· Correct placement of the feeding tube in the stomach or upper jejunum has to be controlled to

avoid dislocation and aspiration;· Placement of a feeding tube into the upper jejunum is a special challenge in daily practice;· Enteral feeding via tube can be delivered as a bolus or continuously, depending on the clinical

situation;· After the start of feeding gastric reflux has be controlled and a treatment algorithm for high

gastral reflux should be given;· The indications for propulsive drugs have to be defined.

Module 8.4 Formulae of Enteral Nutrition

Learning Objectives

· To know about the different types of “dietary foods for special medical purposes”;· To understand what formulae should be used in what condition;· To understand the metabolic effects of single special nutrients added to some formulae.

Contents

1. General characteristics1.1 Nutritionally complete/incomplete formulae1.2 Low, normal and high energy formulae1.3 Whole protein formulae

1.3.1 Standard formulae1.3.2 High energy formulae


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1.3.3 High protein formulae1.4 Peptide-based formulae1.5 Free amino acid formulae1.6 Ingredients of enteral formulae

2. Disease-specific formulae2.1 Diabetes formulae2.2 Liver formulae2.3 Renal formulae2.4 Pulmonary formulae

3. Immune-modulating formulae4. The individual effects of single special nutrients:

4.1 w-3 fatty acids4.2 Arginine4.3 Glutamine

Key Messages

· Formulae for EN, so called “dietary foods for special medical purposes”, are defined in theEuropean legal regulation of the commission directive 1999/21/EC of 25 March 1999;

· Standard enteral formulae have a composition which reflects the ideal values for macro- andmicronutrients for a healthy population;

· Disease-specific enteral formulae are modified standard enteral formulae designed to meet thespecial metabolic demands of the diseased body;

· The energy components of enteral formulae are semi-natural in the sense that common highquality staple are used as basis (milk, soy, different kinds of plant oils, corn);

· The addition of nutrients to some formulae in amounts not regularly reached by normal food, forinstance, glutamine, arginine, nucleotides, omega-3 fatty acids, antioxidants, adds a value asfunctional food, usually to modify immune functions and/or wound healing.

Module 8.5 Monitoring and Complications of Enteral Nutrition

Learning Objectives

· To understand the most important complications of EN;· To know how to prevent or counteract complications;· To know how to monitor patients on enteral nutritional support.

Contents

1. Gastrointestinal complications of EN1.1 Diarrhoea1.2 Nausea and vomiting1.3 Constipation

2. Aspiration3. Tube related complications4. Metabolic complications5. Monitoring of EN

Key Messages

· Most complications of EN are the results of application errors;· Certain underlying diseases are associated with increased risk of specific complications;· Acceptance of EN can be enhanced by adequate monitoring / early recognition of complications

and modification of type of EN and application;· Careful monitoring of EN is especially important in intensive care, in elderly patients and in

patients with neurological impairment.


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Topic 9 Approach to Parenteral Nutrition (PN)

Module 9.1 Indications and Contraindications for Parenteral Nutrition

Learning Objectives

· To identify indications for parenteral nutrition;· To know the basis of recommendations for parenteral nutrition;· To understand the role of parenteral nutrition in clinical outcome.

Contents

1. Introduction2. Indications for PN

2.1 PN as replacement therapy in GI failure2.2 PN versus EN2.3 Elective PN for bowel rest2.4 Comparing different intravenous substrates

Key Messages

· Parenteral nutrition is indicated when nutritional support is required but EN is not feasible for anyreason;

· The indications for PN depend partly on the availability of an expert nutrition team, as in inexperthands the results can be poor and the complication rate high;

· In a limited number of conditions e.g. radiation enteritis, PN, though not necessarily mandatory,can provide a useful period of bowel rest while the underlying problem subsides. This may betermed “elective PN”.

Module 9.2 Techniques of Parenteral Nutrition

Learning Objectives

· To select the best venous access for PN administration considering the advantages and risks of eachsite;

· To describe the protocols (insertion and manipulation of the catheter, administration set, pump,filter, etc. for assuring the safe administration of PN;

· To consider the best types of PN bags to assure adequate administration.

Contents

1. Introduction2. History3. Basic principles of central venous catheter (CVC) placement

3.1 Proper patient preparation3.2 Proper timing of catheterization3.3 Proper skin preparation3.4 Availability of proper equipment and supplies

4. Central venous cannulation4.1 Position of the distal tip

5. Central venous catheters


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5.1 Material used for venous catheters5.2 Types of catheter

5.2.1 Catheters for peripheral veins5.2.2 Catheters for central veins5.2.3 Long-term parenteral nutrition

6. Handling connections of nutrition bags7. Administration sets8. Preparation and choice of parenteral solutions

Key Messages

· The subclavian vein should be the site of first choice for inserting a catheter for PN administration;· A peripheral route can be used for short periods of PN (with low osmolality solutions);· Strict protocols are mandatory for handling of the central venous catheter;· Pump for regulating the flow is recommended; the use of filter is still debatable;· The selection of PN bags (hospital-made or commercialized ready-to-use) should be based on the

patient's needs and expected duration of PN.

Module 9.3 Compounding, Drugs and Nutritional Admixtures in PN

Learning Objectives

· To know the different systems for parenteral nutrition; their advantages and limits;· To know the risks associated with the compounding/ready-to-use preparation of AiO PN admixtures

(GMP and potential incompatibility reactions) and the pharmacist’s tasks and responsibility for anadmixing service;

· To understand the general advice not to admix drugs to PN AiO admixtures, unless documented orof a vital need;

· To understand to apply a risk assessment for adding an i.v. drug to an AiO admixture for both theinfluence of a drug on a PN admixture and the influence of a PN admixture on the fate of a drug.

Contents

1. Introduction1.1. PN: from separate nutrient infusion to the all-in-one admixture1.2. AiO admixtures: prerequisites, benefits, and limits1.3. Industrial PN admixtures: the multi-chamber bag

2. PN compounding and admixing2.1. Good Manufacturing Practice (GMP)2.2. Aseptic preparation technique2.3. Compatibility and stability aspects of AiO admixtures2.4. Drug admixing to an AiO PN formulation

Key Messages

· The all-in-one concept is a milestone in the search for safe, efficient, and convenient PN in acuteand (home) long-term treatment. It has stimulated technical and pharmaceutical developments;

· Standard AIO regimes are used in most cases for PN treatment of adult patients in hospital acutecare. Nevertheless, individualised and tailor-made PN admixtures are also needed to meet thespecific nutritional requirements of children (growth), those with severe illnesses including organfailures, and patients on a long-term (home) PN. Well designed cost-effectiveness studies are stilllacking;

· The compounding of AiO admixtures or the final ready-to-use preparation of industrial AIOpremixes are critical pharmaceutical issues. Good manufacture practice (GMP) rules have to berespected when compounding AiO PN or admixing nutritional components and drugs. Thepharmacist as the manufacturing supervisor has to take specific responsibility to guarantee quality


28

and stability of ready-to-use prepared admixtures. As a nutrition support team member he has todefine and implement standards of correct storage and handling of AiO admixtures. Thesestandards must reflect professional state of the art practice;

· Because of their complex composition and the character of o/w emulsions, PN AiO admixtures havehigh and potentially harmful instability risks. Instability reactions include physico-chemicalincompatibilities and microbial instability due to incorrect aseptic manipulation technique both ofwhich represent avoidable medication errors. The most important incompatibility and instabilityreactions in AiO admixture can be classified according to their physico-chemical reaction type:emulsion deterioration, lipid peroxidation, oxidation of vitamins, and formation of insolubleprecipitates. Measures to avoid them therefore need pharmaceutical expertise and advice anddepend on the characteristics of the pharmaceutical nutrient or drug concerned;

· AiO admixtures are not suitable as drug vehicles due to their complex formulation and the highpotential for interaction in vivo and in vitro. If admixture of a drug is necessary, it is helpful tohave a simple and easy to understand procedure for risk assessment, based on the degree of needfor the medication and on the physico-chemical profiles of the AiO admixture and the drug.

Module 9.4 Monitoring and Complication of Parenteral Nutrition

Learning Objectives

· To understand that maximum efficacy and safety of PN can only be achieved when it is carried outby a properly trained and expert Nutrition Team;

· To realise that monitoring, using data recorded in serial form is a vital tool for achieving optimalresults;

· To understand how to implement monitoring protocols not only to optimise feeding methods andprescriptions but also to prevent complications or at least to detect them at an early stage,allowing timely action;

· To appreciate the technical, mechanical, clinical and infectious complications of PN and howmonitoring helps in their management.

Contents

1. Introduction2. Recording of data3. Monitoring clinical indications

3.1. Acute and critically ill patients3.2. Post-acute patients3.3. Preoperative malnutrition3.4. Chronic malnutrition

4. Monitoring Parameters4.1. Clinical4.2. Anthropometric indices4.3. Nutrition screening and assessment tools4.4. Anthropometric function4.5. Laboratory4.6. Practical considerations

5. Complications of PN5.1. Metabolic complications5.2. Technical complications

5.2.1 Technical complications of peripheral PN5.2.2 Technical complications of central PN

5.3. Infectious complications5.3.1 Pathogenesis5.3.2 Prevention


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Key Messages

· The efficacy of PN is dependent on having an expert team to carry it out;· Clinical and laboratory monitoring are essential tools for the team to achieve optimal results;· Data should be recorded in an easily retrievable serial form in order to give a dynamic picture of

the rate, direction and degree of any change, allowing anticipation of problems and earlyintervention;

· Proper monitoring not only allows early detection of complications and timely intervention but alsocontinuous adaptation of nutritional support to the needs of the patient;

· The appropriate monitoring protocol may vary according to the patient’s underlying clinicalcondition;

· PN is potentially associated with technical (e.g. mechanical), clinical (e.g. thrombotic), metabolic(e.g. hyperglycaemia), and infectious complications, which are largely preventable;

· Adherence to strict protocols and guidelines (e.g. in the insertion and care of central lines) andtheir conduct by trained staff reduces the risk of PN related complications and improves overalloutcome.

Topic 10 Nutritional Support in Pediatric Patients

Module 10.1 Nutritional Support in ICU Pediatric Patients

Learning Objectives

· To understand the main physiological principles of metabolic stress response in pediatric patients;· To understand principles of building up adequate nutritional support strategy for pediatric ICU

patients of different ages.

Content

1. Metabolic changes in critical conditions1.1 Regulation1.2 Pathophysiological pathways1.3 Substrate utilization

2. Estimation of nutritional needs2.1 Energy2.2 Proteins

3. Enteral nutritional support3.1 Indications3.2 Routes and rate of administration3.3 Specialized formula3.4 Monitoring of enteral nutritional support3.5 Complications of enteral nutritional support

4. Parenteral nutritional support4.1 Indications4.2 Route of administration4.3 Fluid and electrolyte balance4.4 Macronutrients4.5 Vitamins and trace elements4.6 Technical aspects of parenteral nutrition

4.6.1 Venous access4.6.2 Rate of nutrient administration

4.7 Monitoring of parenteral nutritional support4.8 Complications of parenteral nutritional support

5. Immune nutrition6. Antioxidants


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Key Messages

· In spite of the great variety of reasons that can cause critical states, initial physiological stressresponse and metabolic changes that take place later are similar in the most critical conditions;

· Enhanced production of stress hormones, mediators and other physiologically active substancescause increased energy expenditure and catabolism of body proteins;

· Adequate nutritional support aims to minimize own tissue catabolism and to prevent dysfunction ofcardiovascular, respiratory and immune function;

· Optimal nutritional support is based on correct estimation of patient overall condition, water,electrolyte and substrate requirements concerning the age specific physiological characteristics;

· Requirements for growth and organ development should be considered in nutrition management ofpediatric ICU patients;

· Enteral nutrition, even in minimal amounts, should be considered always when possible.

Module 10.2 Parenteral Nutrition in Pediatric Patients

Learning Objectives

· To review basic concepts of parenteral nutrition (PN) in infants, children and adolescents;· To define indications for and contraindications to PN in pediatric patients;· To appreciate specific ethical issues of PN in infants, children and adolescents;· To review parenteral feeding requirements, including water, energy, amino acids, glucose, lipids,

minerals and trace elements, and vitamin;· To understand specific challenges of venous access in infants and children, including placement,

care and complications;· To be able to initiate EN and to wean the patient from continuous tube feeding;· To review current standards for ordering and monitoring of PN in hospital settings;· To discuss the advantages of home PN in pediatric patients as well as current concepts for its use;· To review possible complications of pediatric PN as well as strategies for their prevention and

management.

Contents

1. Basic concepts of parenteral nutrition (PN) in infants, children and adolescents1.1 PN in pediatric patients1.2 Indications for PN1.3 Ethical aspects

2. Parenteral substrate supply2.1 Fluid and Electrolytes2.2 Energy2.3 Amino acids2.4 Glucose2.5 Lipids2.6 Minerals and trace elements2.7 Vitamins

3. Venous access4. Ordering and monitoring PN in hospitals5. Home parenteral nutrition6. Complications and their prevention and management

Key Messages

· Parenteral nutrition (PN) is indicated when an adequate energy and nutrient supply cannot beachieved by oral or enteral feeding.

· PN is usually not indicated in patients with adequate small intestinal function who can be enterally(tube) fed.

· PN ordering and monitoring should follow agreed algorithms to improve quality of care.


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· Infants, children and adolescents should be evaluated 2-3 times/week to detect consequences ofinadequate nutrient supply (e.g. clinical examinations, weight change relative to percentile values,anthropometry, laboratory values, evaluation of parenteral and enteral nutrient supply, asappropriate for the patient).

· The best option for infants and children, depending on long-term PN, that do not needhospitalization for other reasons is home PN (HPN), which often markedly improves the quality oflife of these children and their families.

· The establishment of multi-disciplinary pediatric nutrition support teams, which can considerablyenhance the quality of PN and of overall nutritional care, is strongly recommended for alltreatment centers caring for infants and children.

· The evidence based guidelines on paediatric parenteral nutrition established by ESPGHAN andESPEN should guide practice, including dosage of substrate supply.

Module 10.3 Enteral Nutrition in Pediatric Patients

Learning Objectives

· To discuss principles and specifics of EN in children;· To define indications for and contraindications to EN in children;· To describe nutrient composition of various enteral formulas;· To present enteral formula selection adjusted for pediatric patients;· To discuss principles of feed administration in respect of sites, routes and modes of EN delivery;· To be able to initiate EN and to wean the patient from continuous tube feeding;· To discuss the reasons for and mechanisms of possible complications; to give recommendations for

prevention;· To discuss issues of enteral versus parenteral nutrition;· To present benefits and principles of home enteral feeding.

Contents

1. Basic principles of enteral nutrition (EN) in children1.1 Specifics of Pediatric Age1.2 Type of Nutritional Intervention1.3 Definition of EN1.4 Indications and contraindications

2. Nutrient composition of enteral formulas2.1 Carbohydrates2.2 Proteins2.3 Lipids2.4 Fiber2.5 Micronutrients2.6 Nutrient density and osmolarity

3. Enteral formula selection3.1 Polymeric formula selection3.2 Oligomeric formula selection3.3 Monomeric formula selection3.4 Modular feeds

4. Administration of EN4.1 Sites of EN delivery4.2 Routes of EN delivery4.3 Modes of delivery4.4 Initiation of EN4.5 Weaning from EN

5. Monitoring and complications6. Enteral versus parenteral nutrition7. Home enteral nutrition


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Key Messages

· Enteral nutrition is a safe and effective method of nutritional therapy in pediatric patients;· Enteral nutrition should be introduced in a child who has at least some GI function , but is unable

to meet full dietary requirements by the oral route;· Enteral formulas differ substantially in their nutrient content and physical properties; selection

depends on the age and clinical condition, but for the majority of patients standard polymericenteral formulas are the appropriate choice, and with the best cost-benefit ratio;

· Intragastric feeding is the preferred method of enteral feeding as it is associated with highertolerance and fewer complications;

· Technical, metabolic, gastrointestinal, infective and psychological complications may occur duringenteral nutrition, and therefore, close monitoring and strict adherence to the established protocolsare of crucial importance;

· The main advantages of enteral over parenteral nutrition include preservation of gastrointestinalfunction, cost, manageability, and safety.

Topic 11 Organization of Nutritional Care. Ethic and Legal Aspects

Module 11.1 Organization of Nutritional Care (NST)

Learning Objectives

· To appreciate the problem of disease related malnutrition;· To understand that it is often failure of organization and implementation which is the main barrier

to improving nutritional care;· To be able to develop organizational models, protocols and systems to coordinate a

multidisciplinary approach to nutritional care.

Contents

1. Introduction2. Policy, Standards and Protocols3. Hospital food and catering4. Education and training5. Dietetics6. Nutritional support teams7. Purchasing and Equipment

Key Messages

· Improved organization of nutritional care will have both clinical and economic benefits in thehospital service;

· Tucker has shown that two days earlier intervention saves one day in hospital and has calculatedpotential savings of one million dollars a year in the average American Hospital;

· Certain groups e.g. the elderly and those with chronic disease are at risk of malnutrition in thecommunity and should also be identified and treated;

Module 11.2 Ethic and Legal Aspects

Learning Objectives

· To understand the principle of medical ethics;· To appreciate how these affect the practice of nutritional care;


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· To appreciate some legal aspects of this practice.

Contents

1. Introduction2. Beneficence and non maleficence3. Autonomy4. Special situations5. Malignant disease6. Motor neuron disease (MND)7. Dementia

Key Messages

· Ethical and legal considerations increasingly influence clinical decisions;· Increased complexity of decisions in our technical and medico-legal climate in which the patient

is better informed;· The physician's first duty is to the patient (beneficence, non maleficence) but he or she also has

a duty to society (Justice);· It is the responsibility of society as a whole to decide what resources are to be devoted to health

care after full and public discussion and consultation;· The patient's autonomy must be respected but no physician can be forced to undertake

treatment that is futile or that he or she considers against the patient's interest;· The interest of the individual must however be protected against arbitrary action or decisions by

government, purchasing bodies, insurance companies or individuals by a Bill of Rights which issafeguarded by the courts acting independently of government;

· Care of the sick entails the basic duty of providing adequate and appropriate fluid and nutrientsby mouth;

· As long as a patient can swallow and expresses a desire or willingness to drink or eat, fluid andnutrients should be given provided that there is no medical contraindication. This is basic care.Artificial feeding by tube or by vein is a medical treatment.

Topic 12 Nutritional Support in Gastrointestinal Diseases

Module 12.1 The Compromised Gut

Module 12.2 Nutrition after Extensive Gut Resections (Short BowelSyndrome)

Learning Objectives

· To recognize the impact of extensive small bowel resection on digestion, absorption andmetabolism;

· To understand that the consequences of a resection differ depending on the function and extent ofthe removed segment, e.g. resection of ileum with the ileo-caecal valve, is more deleterious thanresection of the jejunum;

· To understand, recognize and treat secondary conditions related to small bowel resectionincluding: diarrhea, malabsorption of macro, - and micronutrients, hypersecretion of gastric acid,bacterial overgrowth, and development of oxalate renal stones and cholesterol gallstones, andmetabolic acidosis;

· To understand the nutritional goals for patients with SBS and the role of enteral nutrition instructural and functional adaptation in the small bowel remnant.


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Contents

1. Etiology2. Pathophysiology3. Complications of SBS4. Gastric acid hypersecretion5. D-lactic acidosis6. Nephrolithiasis7. Cholelithiasis8. Liver function disorders9. Small bowel adaptation10. Management of SBS11. Dietary management of SBS12. Fluid and electrolytes13. Sodium14. Potassium15. Magnesium16. Calcium17. Water18. Macronutrients19. Carbohydrates20. Fat21. Protein22. Alcohol23. Micronutrients24. The role of the dietitian in SBS25. The dietitian should monitor and follow the patient in the following way?

Key Messages

· Short bowel syndrome (SBS) is characterized by diarrhea, fluid and electrolyte depletion,malabsorption of nutrients, and weight loss;

· After resection of the jejunum, the ileum is able to assume most absorptive functions; thereforeresection of the ileum is metabolically more detrimental;

· Removal of the ileo-caecal valve causes a further shortening of intestinal transit time and increasesthe risk of retrograde bacterial colonization of the small intestine;

· Careful fluid end electrolyte replacement and nutritional therapy play a critical role in thetreatment of SBS;

· In most cases parenteral nutrition is necessary, in the early stages, to prevent malnutrition, but, assoon as possible, enteral and oral nutrition should be started and TPN reduced as far as possible;

· Enteral nutrition stimulates bowel function and intestinal adaptation;· In some patients long-term parenteral, combined with oral or enteral nutrition, becomes necessary

and is provided at home.

Module 12.3 Nutritional Support in Gastrointestinal Fistulas

Learning Objectives

· To recognize the impact of GI fistulas at different levels on digestion, absorption and metabolism;· To understand the role of nutrition and metabolic care in the spontaneous healing of fistula;· To understand the role of enteral nutrition in maintaining intestinal integrity, reducing infection

rate and decreasing bacterial translocation.

Contents

1. Introduction2. Principles of management


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3. Approach to fistula management includes

Key Messages

· The therapeutic goals in the management of postoperative EC fistulas are: closure of the fistulaand reestablishment of intestinal continuity;

· Achieving of these goals is not easy, and often impossible in the malnourished patient who hasbeen operated on a short period before the onset of fistula;

· Treatment of fistulae is complex and based on bowel rest, enteral nutrition if possible, butparenteral nutrition if not, pharmacological suppression of secretion, suction drainage, physicalrehabilitation and careful monitoring of all vital functions;

· Whenever possible enteral nutrition should be introduced at least as a part of nutritional support;· Elective surgery should be considered if after 3-5 weeks of nutrition support spontaneous closure

has not occurred;· Emergency surgery is indicated in patients who developed uncontrolled sepsis, or severe

hemorrhage.

Module 12.4 Nutritional Support in Inflammatory Bowel Diseases

Learning Objectives

· To recognize nutritional and metabolic derangements in inflammatory bowel disease;· To learn nutritional monitoring in IBD;· To identify indications for nutritional support;· To perform enteral and parenteral nutrition in patients with IBD.

Contents

1. Effect of inflammatory bowel disease on nutritional status and metabolism2. Indication for nutritional support3. Nutritional support is indicated4. Treatment and prevention of malnutrition5. Dietary recommendations6. Enteral and parenteral nutrition in chronic pancreatitis

Key Messages

· The active phase of inflammatory bowel disease frequently leads to protein energy malnutrition,which in children can lead to growth retardation. Furthermore, specific deficits of vitamins, Fe andCa have been described in some patients;

· Regular nutritional monitoring is, therefore, warranted in all patients with IBD;· Nutritional support is indicated to prevent and treat malnutrition;· Dietary counselling is less effective, therefore sip feeding with standard polymeric diets or tube

feeding are necessary;· Tube feeding may be performed overnight to allow normal oral nutrition by day;· Patients can either swallow a tube every evening, or a PEG may be safely inserted, even in Crohn's

disease;· Intravenous supplementation of vitamins and iron may be necessary in patients with deficiencies

due to reduced absorption or limited tolerance of oral supplements;· Adequate nutritional support improves quality of life in IBD patients;· Enteral and parenteral nutrition are also effective in treating an active phase of Crohn's disease

and are therefore an alternative to medical treatment in patients who are intolerant to orunwilling to take steroids;

· In patients with chronic active CD sip feeding seems to allow reduction in steroid dosage andreduces disease activity;

· An elimination diet is helpful in maintaining remission. The role of pharmaconutritients is still


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controversial.

Module 12.5 Nutritional Support in Acute and Chronic Diarrhoea

Learning Objectives

· To learn about the different aetiologies of acute and chronic diarrhoea;· To be able to diagnose diarrhoea appropriately;· To learn about the different treatment options of diarrhoea.

Contents

1. Aetiologies of infectious diarrhoea (viral, bacterial, parasites)2. Aetiologies of non-infectious diarrhoea3. Diagnosis of diarrhoea4. Management of acute and chronic diarrhoea5. Prevention of diarrhoea6. The role of pre- and probiotics in diarrhoea

Key Messages

· Diarrhoea is major health problem in developing countries;· Diarrhoea is a symptom of different aetiologies;· Most common are viral and bacterial infections. Antibiotic treatment, enteral tube feeding,

diseases involving damage to mucosal lining and endocrinopathies are further important causes ofdiarrhoea;

· Acute diarrhoea is often a self-limited disease and requires only oral rehydration therapy;· The administration of soluble-fermentable fibre enhances colonic sodium and water absorption;· ORS formulation supplemented with soluble fibre are effective in acute and chronic diarrhoea;· Probiotics are effective in the prevention and treatment of diarrhoeal diseases.

Module12.6 Nutritional Support in Irresistible Bowel Syndrome (IBS),Constipation and Diverticulosis

Learning Objectives

· To describe the pathogenesis of the different types of the clinical patterns of IBS;· To understand the importance of food components and intestinal motility;· To understand the limits of dietary treatments in IBS;· To be able to understand the different types of constipation (primary idiopathic constipation,

secondary constipation);· To understand the role of fibre in the pathogenesis of constipation;· To be able to recommend an appropriate nutritional treatment· To understand the clinical impact of the presence of diverticulosis;· To know the complications of diverticulosis;· To be able to manage patients with diverticulitis and other complications.

Contents

1. Definition of IBS2. Pathogenesis of IBS3. Diagnostic work up of IBS4. Nutritional intervention in IBS


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5. Limits and outlook in the treatment of IBS6. Definition of different types of constipation7. Pathogenesis of constipation8. Diagnosis of constipation9. The role of fibre intake and constipation10. Treatment of constipation

10.1 Dietary recommendation10.2 Laxatives10.3 Drugs

11. Epidemiology of diverticulosis12. Pathogenesis of diverticulosis13. Fibre hypothesis and diverticulosis14. Clinical presentation of diverticulosis15. Complications of diverticulosis16. Management of diverticulosis complications17. Dietary management of diverticulosis and complications

Key Messages

· The pathogenesis of IBS is still difficult to understand;· IBS is an intestinal motility disorder with abdominal pain in stool irregularities (constipation,

diarrhoea, or a combination of both);· Food components can play a role in causing symptoms;· Diagnosis can be made using the Rome II criteria;· Dietary treatment of IBS is of limited effect;· Constipation is a common disease with a predominance in women;· Constipation is not a unique disease, different mechanisms are involved;· Diagnosis of chronic constipation can be made by the Rome II criteria;· Fibre intake is only one component in the pathogenesis;· Different treatment options are recommended in different types of constipation;· Increase in fibre intake results only in a modest improvement in constipated patients;· Diverticulosis is common and the prevalence increase with age;· Most of the time diverticulosis causes no symptoms (only about 20% of patients with diverticulosis

have symptoms);· Common complication of diverticulosis are diverticulitis and less more common bleeding;· Fibre rich diets can be used to reduce symptoms and may be to reduce diverticula formation;· Recurrent diverticulitis attacks should be treated by surgery.

Topic 13 Nutritional Support in Liver Disease

Module 13.1 Nutritional Support in Acute Liver Disease

Learning Objectives

· The metabolic problems of patients with acute liver failure.· The caveats regarding administration of glucose and amino acids.

Contents

1. Introduction2. Pathophysiology3. Metabolic response

3.1 Glucose metabolism3.2 Lipid metabolism3.3 Amino acid metabolism

4. Energy and substrate requirements


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4.1 Energy requirements4.2 Protein requirements4.3 Carbohydrates and lipid requirements4.4 Vitamins and mineral requireme

Documents

Module Catalogue List of Modules - lllnutrition.comlllnutrition.com/old/Old files 2017/ModuleCatalogue2008_old2.pdf · Module Catalogue Short description of modules to be developed