Clinical nutrition in the hepatogastroenterology curriculum

Table 1 Requirements for basic nutrition training

Pathophysiology of the gastrointestinal tract and its motility regulation

Metabolism in health and disease

Diagnosis of nutritional status and GI function

General understanding of dietary requirements in health and disease

Understanding of disease-related digestive and metabolic dysfunction, diagnosis and treatment of intestinal failure

Diagnosis and treatment of obesity

The ability to perform and understand the limitations of more complex nutrition treatments and metabolic derangements in healthy subjects and diseased ones, including enteral and parenteral nutrition strategies

Expertise in multidisciplinary care

Ability to collaborate in (translational) research

Table 2 Elements of the suggested modular teaching program on clinical nutrition for hepatogastroenterology specialists

Knowledge of key issues in nutrition

GI physiology

Anatomy

Digestion

Absorption

Motility

GI endocrinology/hormones

Physiology and metabolism of body composition, energy homeostasis

In health

Satiety/needs, calculations, measurements, techniques

Concerning:

Fat

Carbohydrates

Protein

Energy

Micro elements/vitamins

Starvation: Differential diagnostics and clinical management

Obesity: see below

Interventions

Artificial nutrition

Tube feeding/Enteral/PEG tube insertion

Parenteral nutrition

Administration:

access techniques and complications

Complications and safety

Risk-benefit analysis

Enteral nutrition

Parenteral nutrition

Normal (per oral) feeding

Feeding and artificial orificia

Use of nutrition with stress metabolism

Pathophysiology of digestion

Diseases of digestion and absorption

Diseases of impaired nutrient delivery

Protein-losing enteropathies

Pathophysiology of metabolism

Stress metabolism

Metabolism in Critical Illness

Nitrogen wasting

Genetic Metabolic disorders (e.g., OTC)

Special Diets

Nutrition and psychology

Role of psychological issues

Specific clinical situations

Kidney and liver disease

Catabolism/malnutrition

Cancer

Inflammation

Use of PN

Indications

Designing a formula

Monitoring for complications

Techniques

Feeding tubes: nasogastric/nasojejunal

PEG/PEJ/PRG

PEG-J

Jejunostomy [surgically created (Witzel’s) fistula or needle jejunostomy]

Central venous access: (tunnelled) catheters

Peripherally inserted central catheters (PICC)

Subcutaneous ports/arteriovenous fistulae (shunts)

Table 3 Diagnostic matrix nutritional status

Medical factors	Functional factors
Age, sex	Hand grip strength
Medical diagnosis, disease stage/characteristics	Walking speed
	Activities
Hospital admission/surgery/treatment	Exercise/sports
Laboratory results	(I)?ADL dependency
Gastro-intestinal complications
Appetite
Difficulties in chewing and swallowing
Anthropometry (body weight and height, weight loss/gain)
BMI
Body composition (fat free mass/fat free mass index)
Energy expenditure (resting energy expenditure and total energy expenditure)
Nutritional intake
Medication
Mental factors	Socio-economic factors
Motivation/stage of behaviour change	Financial status
Depression/mental disorder	Work
Cognitive disorder/dementia	Educational level
Mental stress	Activities/interests
Loss response	Degree of participation in society
Disease insight
	Living and family situation
	Social network
	Children
	Availability family care givers
	Transportation options
	Loneliness

Table 4 Weight class an obesity score

Weight class	BMI
Under weight	< 18.5
Normal weight	18.5-25.0
Over weight	25.0-30.0
Obesity
Class I	> 30
Class II	> 35
Class III: Extremely obese	> 40
Class IV: Super obese	> 50

Table 5 Training for obesity

Knowledge about the risks and dietary, pharmacological and surgical techniques to control this

Modular Training for Obesity

Physiology of weight regulation

Hormones

Neurotransmitters

Feedback loops

Pathophysiology of Obesity

Behavioural

Hormonal

Genetic

Intestinal microbiome

Obesity managements

In Health

Diet

Lifestyle

Medications

Surgery

Feeding in disease

Hypocaloric feeding

Nitrogen balance

Bariatric surgery management strategies

Restrictive Surgery (Roux-Y gastric Bypass, Gastric band/sleeve)

Diet, vitamin and mineral supplements

Expected weight loss

Monitoring

Complications (dumping syndrome, vomiting, gastro-gastric fistula)

Malabsorptive surgery (Duodenal switch, pancreatico-biliary diversion)

Diet, vitamin and mineral supplements

Expected weight loss

Monitoring

Complications (dumping/rapid transit, dysbiosis, hypoproteinaemia)

Endoscopic Management

Leaks

Strictures

Bleeding

Biliary