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home - Nutrition - Clinical Conditions and Nutrition - Pregnancy Written by Dr Sebastian Zeki
Methods GMP
Knows the role of nutrition as therapy for active IBD SCE 1
Knows the role of dietary alteration in treatment of symptoms of IBD
e.g. low residue diet for stricturing disease
SCE, CbD 1
Knows the mechanism of nutritional deficiency in IBD, the importance
of gut preservation, and the role of nutritional support in IBD
SCE, CbD 1
Understands the circumstances when nutritional support should be
provided by enteral or parenteral routes, and to know the various
methods of delivery
SCE, CbD 1
Understands the possible methods of maximising bowel preservation
including appropriate medical therapy, endoscopic therapy and bowel
preserving surgery
SCE, CbD 1,3
Uses enteral feed as therapy for active disease in appropriate
patients, and to alter diets as appropriate to improve symptoms
SCE, mini-CEX, CbD 1
Can use enteral and parenteral nutrition appropriately to support
patients with active IBD and to prevent substantial malnutrition
mini-CEX, CbD 1
Can perform colonoscopic balloon dilatation to prevent the
requirement for resection, and to understand when to refer for
enteroscopic dilatation or for a surgical opinion
Explains to patients and relatives the importance of nutrition as
treatment and support
mini-CEX, PS 1,3,4
Can work with the MDT to ensure all treatment decisions maximise
bowel length
CbD 1,3
Liaises with dieticians and other healthcare professionals to ensure
that all patients have appropriate nutritional support


Appreciates that preserving bowel length is important
Knows how to use immunomodulating or biological drugs to treat IBD
so as to maintain a maximum bowel length and avoid resections that
may result in a short bowel

Knows endoscopic and surgical techniques that avoid bowel being
resected (e g balloon dilatation and sphincteroplasty)

Knows the dietary therapies available to reduce disease and
symptoms (e g for intermittent obstruction l giving a liquid or low fibre

Appreciates that preserving bowel length is important
Can use immunomodulating or biological drugs to treat IBD so as to
maintain a maximum bowel length and avoid resections that may
result in a short bowel

Can empathise with and appreciate the needs of patients with IBD
Works within the multidisciplinary NST and also with the IBD nurses
and surgeons

Discuss any issue relating the disease honestly with the patient
carers friends and family


Knows the causes of small bowel infarction
Knows the difference between arterial and venous gut infarction
Understands the problems and timing of anastomosing the small
bowel onto the colon

Knows the different methods of imaging the vascular supply to the gut
(e g CT angiography digital subtraction angiography angiograms

Is able to investigate the causes of a small bowel arterial or venous

Can identify other co-existing vascular problems
Can choose the appropriate route for nutritional support (EN or PN)
Be able to feed into defunctioned gut (fistuloclysis) when appropriate
Works within the multidisciplinary NST and with the vascular
surgeons and Haematologists
Appreciates there may be other co-morbidities that limit treatment
Can discuss disease-related issues honestly with the patient carers
friends and family



Knws the principles of normal post operative care including early fluid
management (avoiding excessive saline) and having a knowledge of
when to start nutritional support

Appreciates the reasons why surgical wounds and anastomoses can
break down

Knows the stages of development of an enterocutaneous fistula and
thus the appropriate fluid/nutritional management at each stage

Understands how complex abdominal wounds are dressed (e g
wound manager bags)

Understands what is meant by a frozen abdomen and sclerosing

Knows why intestinal obstruction occurs and the ways in which it can
be managed

Knows why abdominal surgery is best avoided 0- 00 days after the
last abdominal operation

Knows the principles of enhanced recovery after surgery (ERAS)
(including reducing insulin resistance and saline excess)

Can institute an appropriate investigation plan for occult sepsis
Can assess whether an enterocutaneous fistula is likely to close

Is able to prescribe appropriate pain relief (often with the pain team)
Can assess fluid losses and thus give appropriate fluid replacement
Appreciates the principle of later restorative surgery
Is able to arrange the appropriate tests for mapping the remaining gut
(both that is in and out of circuit)

Gives appropriate psychological care with the psychological medicine

Helps a patient to be physically and emotionally well so they are able
to tolerate more surgery if necessary or be able to cope at home

Can feed into defunctioned gut (fistuloclysis) when appropriate
Understands role of tissue viability nurses and can integrate care with

Explains to patients their anatomy the principles of intended
treatment and any procedures



Nutrition in pregnancy Underweight women + low gestational weight gain: High risk of having a low birth weight infant, preterm birth, and recurrent preterm birth.Obese women: High risk of having a large for gestational age infant, postterm birth, incerased risk of childhood obesity.Recommendations for weight gain during singleton pregnancy are:A prepregnancy BMI of 19.8 to 26.0 is normal.12.5 to 18 kg for underweight women — BMI <19.8 kg/m2 11.5 to 16 kg for normal weight women — BMI 19.9 to 26.0 kg/m2 7 to 11.5 kg for overweight women — BMI 26.0 to 29.0 kg/m2 at least 6.8 kg for obese women — BMI >29.0 kg/m2 Nutritional assessment in chronic liver disease-SGA Formal nutritional assessment with the SGA.-Serum albumin, creatinine and INR in patients with compensated cirrhosis.-Micronutrient assessment-Muscle strength, classically measured by handgrip strength,is good predictor of malnutrition-Harris- Benedict Equation to calculate resting energy expenditure (REE) Nutritional Assessment And Renal FailureAnthropometry to monitorAlbumin and Prealbumin is excreted by the kidney so accumulate in renal failure therefore not very usefulPlasma cholesterol concentration- in renal failure the lower the cholesterol, teh higher the risk of dyingBlood urea nitrogen and creatinine- Low predialysis BUN or creatinine levels have also been associated with increased mortality.Plasma transferrin is useful if iron stores are also assessed and determined to be normal. Nutritional support in patients with cancer Parenteral nutrition vs enteral nutrition- no difference in mortalityPerioperative: Feed enterally post-op- less complicationsCan use enteral immunonutrition —to decrease incidence of postoperative infections and length of stayHead and neck: Nutritional support during RT/ operation — less complications but no difference in outcomesAdvanced: No benefit of nutritional support Written by Dr Sebastian Zeki Weight Supplementation Iron — 30 mg. Zinc — 15 mg. Copper — 2 mg. Calcium — 250 mg. Vitamin B6 — 2 mg. Folate — 0.6 mg. Vitamin C — 50 mg. Vitamin D — 5 mcg (200 international units). The RDA for elemental calcium is 1000 mg per day in pregnant and lactating women. IronIncrease iron consumption by about 15 mg/day (to about 30 mg/day) to correct for the 1g total lost trhoguh pregancy.The anaemia should be fully corrected. VegetariansDiets usually deficient in essential amino acids Tx: Fortified soy products, complementary amino acids, more dairy products Fish This contain essential fatty acids, which are important in fetal brain development Lactose IntoleranceLactose intolerance usually better managed in pregnancy but if a problem prescribe calcium CaffeineAssociation between caffeine intake and risk of miscarriage, lower birthweight, and late fetal death ProteinNeed 1.1 g/kg/day (normal=0.8 g/kg/day) CarbohydrateRDA is 175 g/day, up from 130 g/day in nonpregnant women FatDiet low in cholesterol and saturated fat- decrease the risk of preterm delivery.Docosahexaenoic acid (DHA an n-3 polyunsaturated fatty acids (PUFA)) appears to be essential for early brain development during gestation and infancy.Trans fatty acids (TFA) may have adverse effects on fetal growth and development by interfering with essential fatty acid metabolism.Dietary restrictions are not useful. CaloriesIncrease in daily caloric intake by 340 kcal/day in the second trimester and 452 kcal/day in the third trimester. If breastfeeding increase their daily caloric intake by 300 to 500 kcal above prepregnancy levels and consume 1000 mg/day of calcium .

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