Oral Nutritional Repletion

Appropriate treatment of the underlying causes of undernutrition should be accompanied by oral nutritional supplementation in persons who are able to eat. Objective quantitative baseline assessment of food intake is mandatory. This is best achieved by the maintenance of a food diary, in which the patient records all food items consumed over a 72-h period. Review of the food diary also permits evaluation of food preferences and eating patterns. The goal of nutritional supplementation should be the consumption of the recommended daily allowance of macronutrients and micronutrients. Several predictive equations have been derived for the purpose of determining the optimal energy intake for each individual. However, it remains unclear as to what extent corrections have been made for age-related physiological changes in nutritional requirements and energy expenditure. The Benedict-Harris equation is perhaps the best known and most frequently applied. Using this equation, the required daily energy intake in kilocalories is derived as follows:

where W is the weight in kilograms, H is the height in centimeters, and A is the age in years. Upward adjustment is required by factors ranging from 1 to

Table 4 The Council of Nutrition Appetite Questionnaire

1. My appetite is:

1. very poor

2. poor

3. average

4. good

5. very good

1. I feel full after eating only a few mouthfuls

2. I feel full after eating about a third of a meal

3. I feel full after eating over half a meal

4. I feel full after eating most of the meal

5. I hardly ever feel full 3. I feel hungry:

1. rarely

2. occasionally

3. some of the time

4. most of the time

5. all of the time 4. Food tastes:

1. very bad

3. average

4. good

5. very good

5. Compared to when I was younger, food tastes:

1. much worse

2. worse

3. just as good

4. better

5. much better

6. Normally I eat:

1. less than one meal a day

2. one meal a day

3. two meals a day

4. three meals a day

5. more than three meals a day

7. I feel sick or nauseated when I eat:

1. most times

2. often

3. sometimes

4. rarely

5. never

8. Most of the time my mood is:

1. very sad

3. neither sad nor happy

4. happy

5. very happy

Instructions: Complete the questionnaire by circling the correct answers and then tally the results based upon the following numerical scale: A = 1, B = 2, C = 3, D = 4, E = 5. The sum of the scores for the individual items constitutes the CNAQ score. Scoring: If the CNAQ score is less than 28, there is an increased risk of significant weight loss over the next 6 months.

1.5, to compensate for increased activity or pathologically stressful conditions.

For practical clinical purposes, a total daily energy intake of 147kJkg~1 (35kcalkg_1) achieves efficient nutritional repletion. Recent dietary guidelines emphasize an overall healthy and balanced dietary pattern that includes a wide variety of fruits, vegetables, and grain products. Specifically, at least 5 daily servings of fruits and vegetables and 6 daily servings of grain products, including whole grains. Low-fat dairy products, fish, legumes, poultry, and lean meats are encouraged. Guidelines also suggest at least two servings of fish per week.

The current recommended daily allowance for protein is at least 1gkg-1 body weight. However, acutely stressful or hypercatabolic conditions mandate an increase in protein intake to about 1.5 g kg-1. Generally, compliance with these dietary guidelines achieves the dual purpose of ensuring optimal macronutrient and micronutrient intake. This obviates the need for the routine prescription of pharmacological multivitamin preparations in undernourished persons, unless specific signs of micronutrient deficiency are evident.

Nutritional supplementation with regular or fortified natural food items is the ideal mode of nutritional repletion. This possesses the advantages of familiarity, palatability, and cost-effectiveness. Where the patient is reluctant or unable to consume the required total energy intake in natural food items, commercially formulated nutritional supplements are a reasonable alternative. The choice of preparation should be based on palatability and patient preference unless underlying medical conditions such as lactose or gluten intolerance have to be considered. Patients with malabsorption syndromes should be given hydrolyzed preparations to enhance nutrient absorption. Regardless of the preparation used, an attempt should be made to vary flavors, as age-related sensory-specific satiety may limit intake if only one flavor is used. Erroneously, nutritional supplements are often administered with meals. Recent evidence indicates that liquid supplements are more effective in increasing daily energy intake when administered at least 1 h before meals. Data shows that when supplements are administered with meals, a suppressant effect on food consumption is evident. Thus, older adults on nutritional supplements should receive these between meals to maximize net energy intake. Ultimately, in persons with severe undernutrition, the focus should be on energy intake and patient food preference, not on optimal proportions of macro-nutrient and micronutrient intake. Frequently, efforts to ensure a balanced diet necessitate the use of food items that may compromise palatability and result in a counterproductive reduction in food intake.

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