Nutritional Therapy Plan

Four Steps in Developing Optimal Nutritional Therapy

The overarching goal of nutrition therapy is to stabilize or to increase the weight of the patient and to improve their nutritional status. This means ensuring that the patient’s total nutrient intake provides sufficient energy, proteins, micronutrients, and fluid to meet the individual patient’s needs.1 Further objectives of nutritional therapy include maintaining immune functions and preventing metabolic complications.2

In developing a nutritional therapy plan, the following steps are recommended:

  • Define the nutritional goals for the patient
  • Define the patient’s individual nutritional requirements
  • Define nutritional support and implement nutritional therapy plan
  • Define the route(s) of nutrition

Define the Nutritional Goals for the Patient

The first step in developing a nutritional therapy plan is to define the nutritional goal for the patient. For some patients this may mean stabilizing body weight; for others it may mean increasing body weight. A target weight and a target body mass index (BMI) should be defined.

Define the Patient’s Individual Nutritional Needs

The second step in developing a nutritional therapy plan is to define the patient’s specific nutritional requirements. Energy requirements, protein, and fluid intake should all be determined.

The following guidelines will help determine energy requirements:3,4,5

The following guidelines will help determine protein requirements:5,6,7,8,9

The following guidelines will help determine fluid requirements (in ml) by the 100/50/15 formula:10

Define Nutritional Support and Implement Nutritional Therapy Plan

The third step is to evaluate the nutritional intake of the patient and compare it to clinically established requirements. This will reveal any energy and protein gaps for the patient and inform on the appropriate supplementation requirements needed to fill those gaps.

If hospital malnutrition is present, a range of strategies may be used, such as food fortification or the use of enteral or parenteral nutrition. According to the ESPEN Enteral Feeding Guidelines3 the term “enteral nutrition” is used to describe all forms of nutritional support that involve the use of ‘‘dietary foods for special medical purposes’’ independent of the route of administration. Enteral nutrition, therefore, includes oral nutritional supplements (ONS) and enteral tube feeding via nasogastric, -jejunal, or percutaneous tubes. The term “parenteral nutrition” (also known as intravenous nutrition) is used to describe the intravenous infusion of nutrients directly into the systemic circulation, bypassing the gastrointestinal (GI) tract.2

When Supplementation Is Required

The following is a rough guide of a treatment plan for supplementation:11

  • If 100 percent of requirements are met, there is no energy and protein gap and no supplementation is needed.
  • If 75 to less than 100 percent of requirements are met, there is less than a 25 percent gap in energy and/or protein, requiring energy and protein from rich fortified food and oral nutritional supplements.
  • If 50 to less than 75 percent of requirements are met, there is at least a 25 percent gap in energy and/or protein, requiring oral nutritional supplements.
  • If less than 50 percent of requirements are met, the energy and/or protein gap must be supplemented by an energy and protein rich diet with e.g. supplemental tube feeding or total tube feeding.

How to Calculate Fluid Substitution

Fluid substitution may be necessary if a patient does not receive adequate fluids from the food they are consuming. Fluid content of ONS/tube feeding and parenteral nutrition (PN) should also be included in the calculations. Fluid substitution requirements are equal to the total fluid requirement minus fluid intake.1

The following guidelines will help determine fluid substitution:

Define the Route(s) of Nutrition

The fourth step in developing a nutritional therapy plan is to determine the best route or routes of nutrition. The general rule of thumb is – “if the gut works, use it.” However, supplemental or total parenteral nutrition via a central or peripherally-placed line is indicated when nutritional requirements cannot be met via oral or enteral feeding.1

To read more about indications for clinical nutrition types, click here

References
  • 1.National Collaborating Centre for Acute Care (UK). Nutrition Support for Adults Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. NICE Clinical Guidelines, No. 32 London 2006.
  • 2.American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. Clinical Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients. JPEN 2009;33(3):255-259.
  • 3.Lochs H, Allison SP, Meier R et al. Introductory to the ESPEN Guidelines on Enteral Nutrition: Terminology, definitions and general topics. Clin Nutr 2006;25(2):180-186.
  • 4.Report of a Joint FAO/WHO/UNU Expert Consultation. Food and Agriculture Organization of the United Nations. Human energy requirements: Energy Requirement of Adults. 2004.
  • 5.Austrian Society of Clinical Nutrition (AKE). Recommendations for enteral and parenteral nutrition in adults. Vienna 2008.
  • 6.Agostoni C, Bresson JL, Fairweather-Tait S et al. Scientific Opinion on Dietary Reference Values for Protein. EFSA Journal 2012;10(2):2557(66pp).
  • 7.Arends J, Bodoky G, Bozzelti F et al. ESPEN Guidelines on Enteral Nutrition: Non-Surgical Oncology. Clin Nutr 2006;25:245-259.
  • 8.Planth M, Cabre E, Riggio O, et al. ESPEN Guidelines on Enteral Nutrition: Liver Disease. Clin Nutr 2006;25:285-294.
  • 9.Cano N, Fiaccadosi E, Tesinky P et al. ESPEN Guidelines on Enteral Nutrition: Adult Renal Failure. Clin Nutr 2006;25:295-310.
  • 10.Chidester J, Spangler A. Fluid intake in the institutionalized elderly. J Am Diet ASSOC 1997;97:23-29.
  • 11.Jonkers C, Klos M, Kouwenoord K et al. Guideline – Screening and treatment of malnutrition. Dutch Malnutrition Steering group, Amsterdam 2011. Retrieved from Guideline - Screening and treatment of malnutrition.pdf

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