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Modular
Nutrition
Publications Nutritional Rescue, Starter Packs
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When I was a medical student learning therapeutics, our assignments were exclusively to write the admission orders on patients coming into hospital with a variety of diseases. There was a standard routine -activity level, nursing orders, diet, investigations, and medications. Since I was in a downtown teaching hospital in a big city, a disproportionate number of patients were alcoholics, poor or elderly and infirm - malnutrition was common, if not assumed. It was permissible to include an order for B-vitamins - added to the intravenous, if you had one, or taken orally. Big drug companies had established the hospital market for B- complex vitamins both injected and oral. One popular oral B complex included Vitamin C in a bright capsule. No one complained if you routinely ordered this supplement. On the other hand, no one complained if you failed to order the B complex. Thiamin was given to alcoholics and vitamin B12 only to patients with laboratory-proved deficiency. Vitamin C was not prescribed alone but was permissible in a B-complex tablet. We seldom saw scurvy or did not recognize it if we did. Other vitamins, were ignored or some, such as Vitamin E, were taboo because only "fringe' practitioners used such things. Oral mineral supplements were rare except for iron and potassium. Iron deficiency was well recognized as an anemia and iron supplements were popular. Potassium supplementation was commonplace because we were taught to prescribe potassium-wasting diuretics and replace potassium by prescribing tablets or powders added to juice. Magnesium supplementation was usually not considered. The admission MD always wrote diet instructions to be carried out by the hospital dietitians. These were rudimentary diet prescriptions - food was often by-passed completely with the order NPO (nothing by mouth) or "clear fluids only "and a prescription for intravenous solutions replaced oral nutrition with salt water, and glucose. It was perfectly permissible to starve patients for many days if their disease or our investigations made eating difficult or inconvenient. Often, a patient progressed directly from NPO to DAT (diet as tolerated) and the physician had no idea what the hospital was feeding his patients. I found out later that there were hidden benefits to NPO - the benefits of fasting; many patients got better NPO because they stopped eating their usual diet that had been making them ill. It is surprising how little has changed in hospital nutrition since I interned in a teaching hospital. Although a whole technology of intravenous feeding has emerged the benefits are doubtful and oral feeding has taken last place, overwhelmed by the more glamorous technologies that often fail when nutrition is neglected. The human body needs a steady supply of 40 nutrients or it doesn't work. Some institutions have made improvements in the nutritional care of patients in critical care situations. The literature which supports this effort has expanded rapidly with the result that it is an esoteric field only understood by a small number of physicians The commercial development of infant feeding formulas and hospital nutritional products has added to nutritional knowledge. A US study showed that: " adolescents consumed diets that were low in several essential vitamins and minerals and high in some nutrients related to increased incidence of chronic disease. There were groups of teens who had dietary patterns that placed them at especially high risk, in particular the black and Southern females. Vitamin A, vitamin E, calcium, magnesium, and zinc were the nutrients most often consumed below recommended levels. In addition the females consumed low levels of phosphorus and iron. Percent calories from total fat and saturated fat and mean sodium intakes were above recommended levels for the majority of the sample. Another US report concluded: that 5% of Americans over age 65, or 1.5 million individuals, currently reside in the nation's 20,000 nursing homes; that nutritional deficiencies are common, frequently not recognized. and that opportunities for preventing or correcting under-nutrition exist. Another study concluded: despite eating supervision and assistance, the majority of eating-dependent nursing home residents (EDR) have inadequate intakes of numerous essential macro- and micronutrients. The deficient micronutrient intakes could be normalized by administration of a multivitamin/trace mineral supplement daily. Nevertheless, a minority of patients in nursing homes currently receive such a supplement. In the care of critically injured or ill patients improved nutrition through the use of supplements and enteral nutrient formulas is seen to be important. "Micronutrients play a key role in many of the metabolic processes that promote survival from critical illness. For vitamins, these processes include oxidative phosphorylation, which is altered in the patient with systemic inflammation, and protection against mediators, in particular oxidants. Trace elements are essential for direct antioxidant activity as well as functioning as cofactors for a variety of antioxidant enzymes. Wound healing and immune function also depend on adequate levels of vitamins and trace elements Of extreme importance is the ease with which a deficiency state can develop in the critically ill because of decreased nutrient intakes and increased requirements. Daily intakes up to or exceeding many times the RDA usually are required. Attention to micronutrients is paramount both in optimizing the nutritional management of the critically ill and in the overall management of these patients. It also is essential in promoting positive outcomes and decreasing complications." A paradox has emerged, many health professionals take supplements themselves but do not recommend them to their patients. Their better-informed and more affluent patients take the supplements anyway, and the patients who miss out are the most likely to be malnourished. Various studies have polled different populations to define the prevalence of supplement use. In the USA The FDA Vitamin and Mineral supplement use survey in 1980 found that 42% of adults use some supplement. A repeat of this survey on 1896 showed that 38% were users. Subsequent studies show supplement use hovering at about the same incidence; infrequent or occasional users always out-number regular users. |