Britt Berger, MSSodexo DIFebruary 2014

MEDICAL NUTRITION THERAPY IN THE

PATIENT WITH HIV/AIDS: A CASE

STUDY

HistoryStatisticsBiologyDisease Course and LifecycleAntiretroviral TherapyMedical Nutrition TherapyCase Study PatientMedical Hospital CourseNutritional Hospital CourseCommentsQuestions

OUTLINE

Late 1800s: fi rst human infection

Likely source: chimpanzees in West Africa infected with Simian Immunodefi ciency Virus (SIV)

Humans hunted chimpanzees for their meat and were infected by contact with their blood

Virus slowly spread across Africa and to other parts of the world

HIV in the US: since at least the mid- to late 1970s

First cases of AIDS described in 1981

HISTORY OF HIV/AIDS

More than 1.1 million people are living with HIV Almost 1 in 5 are unaware of their infection

Gay, bisexual, and other men who have sex with men (MSM) are most aff ected

Blacks/African Americans face the most severe burden of HIV

HIV incidence has remained relatively stable in recent years at about 50,000 new infections per year

15,529 people in the US with an AIDS diagnosis died in 2010

636,000 people in the US with an AIDS diagnosis have died since the epidemic began

UNITED STATES STATISTICS

33.4 million people are currently living with HIV/AIDS

More than 25 million people have died of AIDS since the fi rst cases were reported in 1981

2 million people died due to HIV/AIDS in 2008

2.7 million people were newly infected in 2008

Cases have been reported in all regions of the world Almost all those living with HIV (97%) reside in low- and middle-

income countries Sub-Saharan Africa (10% of world’s population/68% of HIV)

Prevention has helped reduce HIV rates in small but growing numbers New infections are believed to be on the decline

GLOBAL STATISTICS

HIV = retrovirus

Retroviruses Contain RNA as their genetic material Use reverse transcriptase to convert RNA into DNA Replicate using the cell’s machinery

Lentivirus “Slow” viruses Long period of time between initial infection and beginning of

serious symptoms Many people unaware of their infection and spread the virus

to others

BIOLOGY OF HIV

CD4 cells: Critical part of the immune system Type of white blood cell (fight infection) Send signals to activate the body’s immune response Normal CD4 count = 500 – 1000 As HIV infection progresses, CD4 count decreases Also known as T cells

Viral load: Measurement of the amount of HIV in the blood As HIV infection progresses, viral load increases

TWO IMPORTANT TERMS

HIV infection has a well documented progression

If an HIV-infected person does not get treatment, HIV will eventually overwhelm their immune system

When used consistently, antiretroviral therapy (ART) prevents the HIV virus from multiplying and destroying the immune system

Research has shown that taking ART can help prevent the spread of HIV to others

COURSE OF DISEASE

2 – 4 weeks after HIV infection

Many, but not all, people develop flu-like symptoms Often described as “the worst flu ever”

Body’s natural response to HIV infection “Acute antiretroviral syndrome” (ARS) Or “primary HIV infection”

Large amounts of virus being produced

High risk of transmitting HIV to sexual or drug using partners during this stage

STAGE 1: ACUTE INFECTION

Period where the virus is living/developing in a person without producing symptoms

No HIV-related symptoms Some people experience mild symptoms

Virus continues to reproduce at low levels

Clinical latency may last for several decades for people who take ART

Lasts an average of 10 years for people not on ART

Still possible to transmit HIV to others

STAGE 2: CLINICAL LATENCY STAGE

1. CD4 cells <2002. Opportunistic infection

Regardless of CD4 count

Immune system is badly damaged Vulnerable to infections

Without treatment, people typically survive 3 years

Once a person has an opportunistic infection, life-expectancy without treatment falls to about 1 year

If a person takes ART and maintains a low viral load, they may have a near normal lifespan and never progress to AIDS

STAGE 3: AIDS

HIV enters the body through sexual contact, transfusions with infected blood, or by injection

Virus attaches to dendritic cells (type of immune system cell) Found in the mucosal membranes that line the mouth,

vagina, rectum, penis, and upper GI tract

Dendritic cells transport the virus from the site of infection to the lymph nodes where HIV can infect other immune system cells

The steps of the lifecycle are important to understand Medications used to control HIV infection act to interrupt

the cycle

HIV LIFECYCLE ANDANTIRETROVIRAL THERAPY

HIV binds to a specific type of CD4 receptor and a co-receptor on the surface of the CD4 cell

Similar to a key entering a lockOnce unlocked, HIV can fuse with the host CD4 cell

and release its genetic material into the cell

STEP 1: BINDING AND FUSION

The enzyme reverse transcriptase changes the genetic material of the virus so it can be integrated into the host DNA

STEP 2: REVERSE TRANSCRIPTION

The virus’ new genetic material enters the nucleus of the CD4 cell and uses the enzyme integrase to integrate itself into the body’s own genetic material where it may “hide” and stay inactive for years

STEP 3: INTEGRATION

When the host cell becomes activated, the virus uses the body’s own enzymes to create more of its genetic material

Also creates a more specialized genetic material which allows it to make longer proteins

The enzyme protease cuts the longer HIV proteins into individual proteins

When these come together with the virus’ genetic material, a new virus has been assembled

STEP 4: TRANSCRIPTIONSTEP 5: ASSEMBLY

Final stage of the virus’ lifecycleVirus pushes itself out of the host cell, taking part of

the cell membrane with itOuter part covers the virus

Contains all of the structures necessary to bind to a new CD4 cell

Process begins again

STEP 6: BUDDING

Introduction of 3-drug combination ART in 1996 revolutionized treatment Significantly decreased AIDS-related morbidity and mortality

5 classes of HIV drugs Each class attacks the virus at a different point in the

lifecycle

A person taking ART will generally take 3 diff erent drugs from 2 diff erent classes Best job of controlling the amount of virus in the body and protecting the immune system Protects against resistance

Nutritional implications

HIGHLY ACTIVE ANTIRETROVIRAL THERAPY (HAART or ART)

Blocks a very important step in HIV’s reproduction process

Act as faulty building blocks in production of viral DNA

Blocks HIV’s ability to use reverse transcriptase to correctly build new DNA Without reverse transcriptase the virus is unable to make

copies of itself

NUCLEOSIDE/NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTIs)

Work in a very similar way to NRTIs

Also block reverse transcriptase and prevent HIV from making copies of its own DNA

NRTIs work on the genetic material

NNRTIs act directly on the enzyme itself to prevent it from functioning correctly

NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS

(NNRTIs)

When HIV replicates it creates long strands of its own genetic material

These long strands must be cut into shorter stands in order for HIV to create more copies of itself

Protease acts to cut up these long strands

Protease inhibitors block this enzyme Prevent the long strands of genetic material from being cut

up into functional pieces

PROTEASE INHIBITORS

Block the virus from entering the cells in the fi rst place

HIV needs a way to attach and bond to CD4 cells Special structures on cells called receptor sites Found on both HIV and CD4 cells

Fusion inhibitors can target those sites on either HIV or CD4 cells and prevent HIV from attaching onto healthy cells

ENTRY/FUSION INHIBITORS

HIV uses the cells’ genetic material to make its own DNA Reverse transcription

The virus then has to integrate its genetic material into the genetic material of the cells Uses the enzyme integrase

Integrase inhibitors block this enzyme and prevent the virus from adding its DNA into the DNA of the CD4 cells

Preventing this process prevents the virus from replicating and making new copies

INTEGRASE INHIBITORS

Overall goals of MNT for HIV and AIDS patients are to:

Optimize nutritional status, immunity, and well-being

Maintain a healthy weight and lean body mass

Prevent nutrient deficiencies

Reduce the risk of comorbidities

Maximize the effectiveness of medical and pharmacological treatments

MEDICAL NUTRITION THERAPY

Good nutrition is important to all people, whether or not they are living with HIV

Eating well is key to maintaining: Strength Energy Healthy immune system

Some conditions related to HIV/AIDS and treatment mean that proper nutrition is EXTREMELY IMPORTANT Wasting Diarrhea Lipid abnormalities

Immune suppression Food safety and proper hygiene

MEDICAL NUTRITION THERAPY

Adequate intake of macro- and micronutrients is essential to restoration and maintenance of body cell mass and normal body function, including immunity

The benefi ts of providing adequate amounts of energy, protein, and micronutrients for people living with HIV are clear However, the EXACT amount of each type of nutrient needed

is less clear

Long-term clinical trials are needed to provide evidence-based formal recommendations for all nutrients

There is no single “diet” that is appropriate for all individuals living with HIV

ESTIMATED NUTRITIONAL NEEDS

Studies show that low energy intake combined with increased energy demands due to HIV are the major driving forces behind HIV-related weight loss and wasting

Asymptomatic HIV-infected adults: Goal = maintain body weight 10% increase in energy needs 25 – 30 kcal/kg 28 – 33 kcal/kg

Symptomatic HIV-infected adults (with opportunistic infections): 20 – 30% increase in energy needs 30 – 40 kcal/kg Intake should be increased to the extent possible during

recovery phase

ENERGY

DRI for healthy adults = 0.8 grams/kg Likely adequate for asymptomatic HIV-infected adults

Patients with wasted lean body mass Increased protein intake may be beneficial 1.2 – 2.0 grams/kg Currently no evidence to support protein intake in excess of

this range

Sources of dietary protein include both animal and plant-based sources Strict vegetarians need to consume a wide variety of foods

to ensure that they obtain adequate amounts of all essential amino acids May benefit from protein, energy, iron, and vitamin B12

supplementation

PROTEIN

No evidence that total fat needs are increased beyond normal requirements

Special advice regarding fat intake may be required for patients undergoing antiretroviral therapy or experiencing persistent diarrhea

Malabsorption syndromes may require changes in timing, quantity, and type of fat intake

Researchers are currently studying the potential of omega-3 fats in immune function Recommendations are currently no different than for the

general population

FAT

Foods rich in micronutrients are likely to help fight infections and improve overall health

Studies suggest that deficiencies and/or high intakes of certain micronutrients may aff ect the course of HIV Selenium deficiency may increase HIV-related mortality Excessive intake of zinc may be linked to poorer survival Increased intake of vitamins B1 (thiamin) and B2

(riboflavin) may enhance survival Other micronutrient deficiencies may exacerbate oxidative

stress associated with HIV infection

The patient is likely to benefit from consuming a varied diet that is rich in micronutrients

MICRONUTRIENTS

WHO’s position on micronutrient supplementation in HIV-infected individuals:

Healthy diet is best

Dietary intake of micronutrients at RDA levels may not be suffi cient to correct nutritional deficiencies

Legitimate use of dietary supplementation is to restore nutritional status to normal

No conclusive evidence to support use of dietary supplements to improve outcomes

Risk of adverse reactions with other medications

MICRONUTRIENT SUPPLEMENTATION

Food and nutrient intakeLifestyleMedical history

Important medical factors to consider with HIV/AIDS patients: Stage of disease (CD4 count, viral load) Comorbidities (CV disease, DM, hepatitis) Opportunistic infections Metabolic complications (DLD, insulin resistance) Biochemical measurements (CD4 count, viral load, albumin,

hemoglobin, iron status, lipid profile, LFTs, renal function, glucose, vitamin levels)

NUTRITION ASSESSMENT

Very important Noted and documented during initial assessment and all follow-

up assessments

Patients must be made aware of possible body shape changes Medical team (including RD) should ask patients about body

shape changes every 3 – 6 months

Anthropometric measurements Measure changes in body shape and fat redistribution

Physical changes = HIV-associated lipodystrophy syndrome

Unintentional weight loss often indicates progression of disease

PHYSICAL APPEARANCE

Mental status and psychosocial issues may take precedence over nutrition counseling

Depression is common

Habits, food aversions, and timing of meals with medications must be taken into consideration

Access to safe, aff ordable, and nutritious food?

Common barriers: Cost, location of supermarkets, lack of transportation, lack

of knowledge of healthier choices Antiretroviral medications are expensive and often compete

with food for available monetary resources

SOCIAL AND ECONOMIC FACTORS

All HIV patients should have access to a Registered Dietitian Baseline nutrition assessment after HIV diagnosis Reassessment 1 – 2x per year for asymptomatic patients 2 – 6x per year for symptomatic but stable patients Patients that have been diagnosed with AIDS usually need to be

seen more frequently and may require nutrition support

RD must implement MNT and coordinate care with the interdisciplinary medical team and community resources

Many cities/towns/communities have resources available for HIV and AIDS patients Food assistance programs Support systems Recreational facilities

INTERDISCIPLINARY CARE

No specific medical nutrition therapy for HIV and AIDS beyond adequately meeting additional energy, protein, fluid, and micronutrients needs

MNT should be individualized for each patient

Focus on: High quality foods Variety of fruits and vegetables Problems identified during nutrition assessment (CV risk, liver disease, DM)

CUSTOMIZING A NUTRITION PLAN

Education and counseling should focus on:

Appropriate and adequate food intake Food behaviors Symptoms that may affect appropriate food intake Benefits and risk of supplemental nutrients Strategies for symptom management

Reduce effects of disease Reduce medication intolerance

NUTRITION EDUCATION

When a patient does not/cannot eat well, supplements may be necessary for getting suffi cient calories, protein, vitamins, and minerals Not perfect substitutes for food Can be helpful

Nutritional supplements can be toxic Safe limits are usually 100 – 200% of the nutrient’s DRI Vitamins A and D are most safely obtained through eating food Zinc and selenium are important for immunity, but are toxic at

fairly low doses

Patients with signifi cant weight loss may be candidates for enteral nutrition (not very common)

Unless GI function is severely abnormal, there is no reason to consider parenteral nutrition

SUPPLEMENTS AND NUTRITION SUPPORT

Diarrhea is common Causes dehydration, malabsorption, food/nutrient

losses Caused by:

Infection GI damage Increased motility Lactose/other food intolerances Medication (ART)

Short-term: Antidiarrheal medications

Long term: Large fluid losses/dehydration Investigation by MD

GI SYMPTOMS AND SIDE EFFECTS

ART medications: Diarrhea, GERD, nausea, vomiting, constipation PI and NRTI classes are most commonly associated with GI

distress Diarrhea can make it diffi cult for ART medications to be as

effective as possible Reduce caffeine and alcohol Test for lactose intolerance

Fat malabsorption Feeling full too fast, bloating, foul-smelling stools that float Low-fat diet Pancreatic enzyme supplementation

GI SYMPTOMS AND SIDE EFFECTS

Nausea Also a common problem Food, medications,

odors Psychological aversions

to food may develop Look at food-medication

interactions Add

anti-nausea/antiemetic medications if necessary

If associated with food intake, implement nutritional strategies

GI SYMPTOMS AND SIDE EFFECTS

Food safety is especially important for patients with low CD4 counts (<200) More likely to get sick from foods that are not safe to eat

Food safety rules: Avoid eating raw eggs, meat, and seafood Wash fruits and vegetables thoroughly Use a separate cutting board for raw meats Wash hands, utensils, and cutting boards with soap and water after each use Water safety is extremely important

Water can carry parasites, bacteria, and viruses

FOOD SAFETY

Dietetic internship primary site = St. Barnabas Hospital in the Bronx Urban level I trauma center

Many patients are HIV-positive in addition to condition that they are hospitalized for

Ideal opportunity to learn more about HIV and AIDS Nutritional implications

CHOICE OF CASE STUDY PATIENT

45 year-old black woman

Brought to the emergency department by EMS with shortness of breath, elevated heart rate, fevers, sweating, frequent vomiting/diarrhea, severe cough with whitish phlegm for two weeks

Past Medical History HIV (non-compliant with ART medications, last known CD4

count = 172 in January 2012) Hypertension Depression PCP pneumonia (required hospitalization) Anemia History of IV drug abuse and tobacco use

PATIENT

Height: 5’2” (62” / 156.4cm)Admission weight: 90# / 40.8kgBMI 16.4

Questionable accuracy of admission weight No mention of what type of scale was used (standing

scale, bed scale, etc.) Was the weight stated by the patient?

Visibly cachecticReport of 40# (31%) weight loss from usual body

weight 130# over the last monthSevere weight loss

PATIENT

Currently unemployedLives alone in an elevator building in the

BronxCompleted high school, did not go to

collegeBaptistPatient’s best friend/on-and-off boyfriend

spent almost every day with her during hospitalization

Sister in Staten Island

PATIENT

October 21, 2013 – November 19, 2013 30 days

High nutritional risk Followed-up every 2 – 3 days Initial assessment 4 reassessments Several progress notes

Emergency department Medical/surgical fl oor ICU Step-down ICU General medicine fl oor Home

MEDICAL HOSPITAL COURSE

Admitting Diagnosis:

AIDSMultilobar/PCP pneumoniaCandida infection of the mouth and esophagus

Acquired Immunodeficiency Syndrome

Final stage of HIV infection

Badly damaged immune system One or more specific opportunistic infections Certain cancers CD4 count <200

Medical intervention necessary to prevent death

AIDS

AIDS-defining condition (opportunistic infection)

Serious illness caused by the fungus Pneumocystis jirovecii

One of the most frequent and severe opportunistic infections in people with HIV/AIDS

Symptoms: Fever Dry cough Shortness of breath Fatigue

In HIV-infected patients: Develops sub-acutely Low-grade fever

No vaccine to prevent PCP

3 week treatment with antibiotics

PCP PNEUMONIA

AIDS-defining condition (opportunistic infection)

Also known as thrush

Fungal infection - Candida overgrowth A small amount of this fungus normally lives in the mouth Usually kept in check by the immune system and other

bacteria

Fungus can overgrow when the immune system is weak Common in HIV/AIDS

Nutritional implications

ORAL/ESOPHAGEAL CANDIDIASIS

PCP pneumonia Antibiotics O2 supplementation Follow-up O2

saturation Respiratory and

sputum cultures

Severe oral thrush Fluconazole and

Nystatin Swish and Swallow

Mostly resolved within the first week

AIDS (non-compliant with ART) CD4 <20

Rule out TB Airborne precautions 3 sputum cultures

Diarrhea Flagyl Stool workup

HOSPITAL DAYS 1 – 8MEDICAL/SURGICAL FLOOR

O2 saturation Red blood cells must carry suffi cient oxygen through the

arteries to all internal organs to keep a person alive Percentage of hemoglobin binding sites in the bloodstream

occupied by oxygen

95% 91% 87% 88% 75%

Possible sepsis WBC 8.2 16.7

Patient states she feels like she is going to die

Transferred to ICU

HOSPITAL DAYS 1 – 8MEDICAL/SURGICAL FLOOR

Patient appears emaciated and weak, dry crusted lips, minimal oral thrush

May require intubation if condition worsens

Discussion about end of life issues Appoints best friend as medical proxy Wishes to be intubated and resuscitated if necessary

Patient begins to feel better O2 saturation improves WBCs trend down Diarrhea resolved Medically stable Ready for transfer to general medicine floor

HOSPITAL DAYS 9 – 15ICU

Patient had episode of Ventricular tachycardia

Rapid heartbeat that starts in the ventricles 5 beats Most likely caused by medication interaction Transferred to step-down ICU instead of general

medicine floor for observation

93 – 100% O2 saturation

HOSPITALS DAYS 16 & 17STEP-DOWN ICU

C. diff negative Diarrhea resolved Flagyl discontinued

Able to walk to bathroom without significant SOB

Chest X-ray shows improvements

Reglan added for GI upset Polypharmacy

Patient tells MD she is interested in restarting ART St. Barnabas Designated

AIDS Center appointment scheduled

Patient will need home O2 when discharged Social work coordinated

with VNS for delivery

PATIENT DISCHARGED

HOSPITAL DAYS 18 – 30GENERAL MEDICINE FLOOR

Very sick

Extremely advanced AIDS CD4 <20

Two opportunistic infections Both with nutritional implications Diffi cult PO intake

First 10 days in hospital 21.6# weight loss Lowest BMI = 12.5 Cachexia and severe protein-calorie malnutrition

DISCUSSION OF MEDICAL NUTRITION THERAPY

HD 1 HD 10 HD 11 HD 12 HD 16 HD 23 HD 2950

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Weight (in lbs.)

WEIGHT DURING HOSPITALIZATION

Chewing problem: Poor dentition

Swallowing problem: Painful/diffi cult

swallowing caused by severe oral/esophageal thrush

Vomiting: Persistent PTA, currently

resolved

Diarrhea: Persistent PTA, multiple

episodes today

Appetite/Intake: Fair, making an effort to

eat ~25% breakfast

completion

Diet PTA: <1 meal/day x2 weeks Inability to cook because

of lack of energy

Appearance: Cachectic

NUTRITION INITIAL ASSESSMENT (HD 2)

Anthropometrics BMI: 16.4 Ideal body weight: 110# / 50kg

%IBW: 82% Usual body weight: 130# / 59kg

%UBW: 69%

Estimated nutritional needs Based on current body weight 41kg Calories: 1435 – 1640 kcals (based on 35 – 40kcal/kg) Protein: 61 – 82 grams (based on 1.5 – 2.0gm/kg) Fluid: 1230 – 1435 ml (based on 30 – 35ml/kg)

High nutritional risk

NUTRITION INITIAL ASSESSMENT (HD 2)

Diagnosis: Malnutrition related to poor PO intake, persistent

vomiting and diarrhea, painful and diffi cult swallowing, and oral/esophageal thrush as evidenced by 40# (31%) unintentional weight loss x 1 month, BMI 16.4

Intervention: Discussed the importance of adequate PO intake and

strategies to achieve adequacy Recommended patient eat protein portion of meal first PO supplement use between meals, rather than meal

replacement Discussed food preferences

NUTRITION INITIAL ASSESSMENT (HD 2)

Recommendation plan:

SLP consult for diet consistency and upgrade from pureed consistency to soft consistency for palatability and PO intake optimization

Ensure Plus 8oz PO supplement TID (1050kcal + 39gm protein) for consumption between meals

Continue MVI supplementation, maintain hydration status, replete electrolytes as necessary

Reassess PO intake

Weekly weights

NUTRITION INITIAL ASSESSMENT (HD 2)

Poor – fair PO intake 10 – 50% meal completion

Consistency upgrade to soft foods

Added yogurt and applesauce to breakfast, lunch, and dinner trays

Food from outside Grapes, candy

Less painful swallowing

Patient seen drinking Ensure Plus supplements

HOSPITAL WEEK 1

Day after ICU transfer

0% breakfast completion, patient was told not to remove her O2 mask

Patient believes Ensure Plus supplement causes diarrhea

Weight: 74.5# / 33.8kg (bed scale) 15.5# (17%) weight loss BMI: 13.6

Estimated nutritional needs (based on IBW 50kg) Calories: 1500 – 1750 kcals (based on 30 – 35kcal/kg) Protein: 75 – 100 grams (based on 1.5 – 2.0gm/kg) Fluid: 1250 – 1500 ml (based on 25 – 30ml/kg)

NUTRITION REASSESSMENT 1 (HD 9)

Interventions and recommendations: Added tuna sandwich and gelatin to patient’s lunch and

dinner trays to give more options Continue soft diet Discontinue Ensure Plus supplements Add TwoCal HN 8oz PO supplement BID (950kcal + 40gm

protein) Reassess PO intake Daily weights

During ICU stay: Added chocolate cake to patient’s dinner trays Added Ensure pudding once daily (170kcal + 4gm protein)

NUTRITION REASSESSMENT 1 (HD 9)

Fair appetite75% breakfast completionObserved patient drinking a TwoCal supplement

Patient noted with 2.8kg (6.2#) weight gain from lowest weight

BMI: 13.6

Patient encouraged by weight gain and motivated to continue gaining weight

NUTRITION REASSESSMENT 2 (HD 17)

Good appetite 75% meal completion Finishes at least 1 TwoCal supplement per day Eats 2 sandwiches as snacks between meals Loves the chocolate cake

Weight: 91.8# / 41.6kg (bed scale) BMI: 16.8 17.3# (23%) weight gain since lowest weight during

hospitalization 2% weight gain since admission

Connection between PO intake and medical condition VERY motivated to continue gaining weight and to leave the

hospital Soft regular consistency foods Linezolid Rx added – Tyramine restriction added to diet order

NUTRITION REASSESSMENT 3 (HD 23)

Continued good appetite

Occasional diffi culty swallowing due to sore throat Patient requests mechanical soft consistency foods

Weight: 88.1# / 40kg (standing scale)BMI: 16.1

3.6# (4%) weight loss x 6 days Possibly due to bed scale vs. standing scale

Patient feels much better and is able to walk around room

Pending discharge, reinforced nutrition education

NUTRITION REASSESSMENT 4 (HD 29)

Initial diet

Discussion about end of life issues Patient realized she was not ready to die Motivated to do anything possible to get better Gaining weight became top priority SUCCESS!

Nutrition at home Supplements covered by insurance?

Trusting relationship Doctors and nurses frequently changed, but my presence and

concern remained constant Significant weight gain = big part of recovery Importance of nutrition team as part of multidisciplinary care

COMMENTS ON MNT PROVIDED

A BIG THANK YOU TO THE CLINICAL NUTRITION DEPARTMENT AT ST. BARNABAS HOSPITAL…

for being amazing preceptors, teachers, and mentors!

Amy (CNM), Allison, Rachel, Bing, Jess, Rebecca, and especially Michelle for helping me find the perfect case study patient

QUESTIONS/DISCUSSION