Summaries of Topics 2022


Topic 3 Nutritional Assessment and Techniques

The modules in this topic have been developed to highlight the present clinical problem of malnutrition and the need for routinely screening patients for malnutrition using validated tools. Students will learn the difference between screening and assessment of malnutrition, and the tools/techniques to be used, with their advantages and limitations. Students will also learn the clinical relevance of body composition and how it can be estimated or measured. The modules will discuss the clinical relevance of energy expenditure and its components, and how it can be estimated or measured. Students will be acquainted to the concept of energy balance, and the strategies available to monitor patients at nutritional risk and their response to nutritional support.

Topic 4 Nutritional Support in Paediatric Patients

The modules of this Topic summarize the evidence, and provide recommendations for clinical practice regarding the following 4 issues:
1. Cow's milk protein allergy as the commonest food allergy in infants and young children.
2. Intestinal failure, as the most severe form of the chronic GUT disorder is discussed in respect to parenteral and enteral nutrition approach.
3. Current strategies to feed the very low birth weight infant from birth to discharge form the hospital. Focus on early provision of nutritional support in order to achieve optimal growth and development.
4. Many risk factors associated with cardiovascular disease in adulthood are present in children including obesity, hyperlipidaemia, sedentary lifestyle and poor nutrition. Nutritional intervention is the primary approach in the management of dyslipidaemias in children and essential complementary intervention in children needing pharmacotherapy.

Topic 6 Malnutrition

Topic 7 Substrates for Enteral and Parenteral Nutrition

The health status and disease require regular intake of appropriate quantity and quality of nutrients. All dietary components: proteins, carbohydrates, fats, vitamins, minerals and water are essential for balanced diet. Nutrients can be delivered via enteral and parenteral route. Standard diets are suitable for most patients, while disease specific formulas or immunodiets has been modified to create optimal conditions for treatment and to increase nutritional status in aspect of disease related disorders.

Topic 8 Approach to Oral and Enteral Nutrition in Adults

The modules of this topic address the relevant clinical issue of oral and enteral nutrition to prevent/treat malnutrition. Students will learn innovative approaches to increase volitional food intake during hospitalization and in the community. Also, attention will be given on the strategies to monitor nutritional intake, and when oral nutritional supplements are indicated. Students will discuss the flow chart to be followed when oral intake is not sufficient in order to properly prescribe enteral nutrition via tube feeding. Consequently, indications and contraindications to enteral nutrition will be presented, together with the different types of nutritional formulae available and the metabolic effects of specific nutrients. Finally, the parameters informing an appropriate feeding protocol will be discussed, to avoid complications of enteral nutrition.

Topic 9 Approach to Parenteral Nutrition

This topic has been developed to provide a comprehensive learning tool to parenteral nutrition (PN). In particular, the modules discuss indications and contraindications to PN, and the benefits vs limitations of different intravenous accesses. At the end of the topic, students will recognize the advantages and limitations of different PN delivery systems, and how to reduce the risk associated with PN compounding (GMP protocol). Pharmacist's role and responsibility when preparing PN mixtures will be presented. In particular, the complex issue of drug-nutrient interactions will be discussed. Also, the parameters informing the development and implementation of a cost-efficient monitoring protocol for patients receiving PN will be discussed, in order to optimize PN and prevent/early detect complications.

Topic 10 Nutritional Support in Pediatric Patients

Disease-associated undernutrition in children results from disease-specific factors, decreased intake and increased losses with or without inflammation. The assessment of nutritional status should be based on more than a single anthropometric measurement, and rather with serial measurements taken over time. The analysis of growth using growth curves and/or z-scores remains the cornerstone for a paediatric nutritional assessment. Nutritional risk screening should be imbedded in any nutritional care algorithm and the important role of the paediatric nutrition support team cannot be overemphasized.
PN is an essential and often life-saving treatment for infants, children and adolescents who cannot be adequately fed orally or enterally.
PN should only be used when all alternative options have been explored, including adequate care, specialised enteral nutrition, and artificial feeding devices.
PN can induce severe adverse effects. The risk is reduced by a meticulous approach, establishment of a multidisciplinary nutrition support team, avoidance of unbalanced or excessive substrate supplies, and the use of strict hygiene measures to reduce catheter infections, concomitant minimal enteral feeding and aggressive enhancement of enteral feeding where possible to limit the amount and duration of PN.
In this module various aspects of enteral nutrition in paediatric patients are discussed. Indications, contraindications, administration of EN, monitoring and complications are described. The nutrient composition of various enteral formulas is presented and criteria for enteral formula selection are described.
Various aspects of the alterations of the metabolism of critically ill children and the consequences for enteral and parenteral nutrition are discussed. Principles of nutritional assessment are described and methods to calculate energy expenditure are given. Indications, contraindications and recommendations for the administration of enteral and parenteral nutrition are described.

Topic 11 Organisation of Nutritional Care. Ethic and Legal Aspects

Topic 12 Nutritional Support in Gastrointestinal Diseases

Nutritional Support in Gastrointestinal Diseases focusses on intestinal failure and inflammatory bowel disease. There are separate Modules on pathogenesis, on the identification and management of short bowel syndrome and on enterocutaneous fistulas, in addition to one addressing nutritional issues in Crohn's disease (and to a lesser extent in ulcerative colitis). The Topic intends to provide a practical guide to a complex area of nutritional practice that is often misunderstood.

Topic 13 Nutritional Support in Liver Disease

To learn the consequences of malnutrition in liver cirrhosis; To know how to diagnose malnutrition in liver cirrhosis and how to treat malnutrition in liver cirrhosis; The metabolic problems of patients with acute liver failure; The caveats regarding administration of glucose and amino acids; To learn how to discriminate between patients with mild or severe pancreatitis; To appreciate the impact of adequate nutritional support on clinical outcome in patients with acute pancreatitis; To learn about the benefits and the risks of enteral and parenteral nutrition in patients with acute pancreatitis; To learn the best approach to nutritional support in patients with severe and complicated acute pancreatitis; To know about the physiology and pathophysiology of CP (chronic pancreatitis); To know the treatment goals in CP with respect to nutrition; To understand the indications for different nutritional interventions in CP. Improvement of competencies and skills in CN, application of effective CN in the treatment of disease and health promotion; To acquire tools to interpret new scientific information, genetic predisposition and link with nutrition, better practical management of nutritional support.

Topic 14 Nutritional Support in Pancreatic Disease

To learn the consequences of malnutrition in liver cirrhosis; To know how to diagnose malnutrition in liver cirrhosis and how to treat malnutrition in liver cirrhosis; The metabolic problems of patients with acute liver failure; The caveats regarding administration of glucose and amino acids; To learn how to discriminate between patients with mild or severe pancreatitis; To appreciate the impact of adequate nutritional support on clinical outcome in patients with acute pancreatitis; To learn about the benefits and the risks of enteral and parenteral nutrition in patients with acute pancreatitis; To learn the best approach to nutritional support in patients with severe and complicated acute pancreatitis; To know about the physiology and pathophysiology of CP (chronic pancreatitis); To know the treatment goals in CP with respect to nutrition; To understand the indications for different nutritional interventions in CP. Improvement of competencies and skills in CN, application of effective CN in the treatment of disease and health promotion; To acquire tools to interpret new scientific information, genetic predisposition and link with nutrition, better practical management of nutritional support.

Topic 15 Nutrition Support in Renal Disease

Patients who develop acute kidney injury (AKI) often have pre-existing or hospital acquired protein-energy malnutrition, which is a major negative prognostic factor in this clinical condition. Despite the lack of evidence the enteral or parenteral route appears clinically indicated in most cases of ICU-acquired AKI to prevent deterioration in nutritional state and complications. Extrapolating from data in other conditions, it seems intrinsically unlikely that starvation of a catabolic patient is more beneficial than appropriate nutritional support by an expert team with the skills to avoid the potential complications of EN and PN.
The primary goals of nutritional support in AKI are the same as those for critically ill patients with normal renal function, i.e., to ensure the delivery of adequate nutrition, to prevent protein-energy wasting with its attendant metabolic complications, to promote wound healing and tissue repair, to support immune system function, to accelerate recovery, and to reduce mortality.
Chronic kidney disease (CKD) patients are sensitive to protein-energy wasting (PEW), and adequate nutritional therapy can yield remarkable improvements in the symptoms of the disease, quality of life, morbidity, mortality and the progression of renal failure. Evaluation of nutritional state in CKD and assessment of dietary intake, including supplements and compliance are steps of crucial importance. The principal causes involve poor dietary intake, abnormal metabolism of amino acids, proteins, lipids and carbohydrates, and metabolic acidosis promoting catabolism. In many complicated CKD patients the main reason for PEW is chronic inflammation.
Insufficient nutritional care and metabolic disturbances mainly due to metabolic acidosis, hormonal disturbances, chronic inflammation and partially from loss of nutrients in heavy proteinuria, are considered as main causes of PEW.
Protein-energy wasting is found in approximately 25% of End-stage Renal Disease Patients on Haemodialysis (ESRD-HD) patients and has a major impact on survival.
Present data show that: 1) nutritional support, preferably in the form of ONS, is able to improve nutritional status; 2) morbidity and mortality can be reduced when improvement of nutritional status, as assessed by a transthyretin increase of 30 mg/l, is obtained during nutritional support. Early administration of nutritional support and rational timing of ONS consumption may improve the efficacy of nutritional support.
All peritoneal dialysis (PD) patients should be regularly monitored in order to detect early signs of PEW. In some groups of PD patients at higher risk of PEW, i.e. anuric PD patients, those with cardiac congestion, inflammation and low nutritional intakes, intensified nutrition counselling and nutritional support, preferably in the form of ONS, may help to cover nutritional requirements. Once PEW is established, ONS or AA-IPPN may improve nutritional status. Whether morbidity and mortality can be reduced by nutritional support in these patients is unknown, although it is likely that it will, considering the positive data obtained in HD patients. The reduction in glucose load obtained by using glucose-sparing solutions improves the metabolic profile of PD patients, although the impact of these solutions on body composition and patient outcomes still needs to be addressed.

Topic 17 Nutritional Support in the Perioperative Period

The aim of the this topic is to present the relationship between perioperative factors, like surgical trauma, malnutrition, stress, lifestyle and the surgical outcome, such as complication rate and mortality, as well as to provide a comprehensive information on how to avoid all detrimental factors, how to carry out perioperative nutrition and how to implement a modern perioperative care into the clinical practice.
The phenomenon of stress encountered after operation, the interactions of counter regulatory hormones and inflammatory response causing insulin resistance and hyperglycemia will be presented. Methods to reduce insulinresistance, including preoperative carbohydrate loading, modern anesthesia and analgesia and the concept of prehabilitation will be discussed. Indications to nutritional support and methods how to perform it will be presented. Actions leading to prevention and treatment of postoperative ileus will be fully discussed.

Topic 18 Nutritional Support in Intensive Care Unit (ICU) Patients

The aim of this topic is to discuss nutritional support in critically ill patients. Methods to assess the nutritional status of ICU patients as well as the indications to nutritional support will be presented. Actions to maintain homeostasis during nutrition care, to evaluate the energy and protein needs and to promote adequate nutrition on a daily basis will be introduced. The use of early enteral feeding, early supplemental parenteral nutrition will be discussed. Indications to immunonutrition will be given and controversies will be reviewed. Prevention and management of the common complications of nutrition support will also be presented.

Topic 19 Nutritional Support outside the Hospital: Home Parenteral Nutrition(HPN) in Adult Patients

Learn about epidemiology and the extent of the use of HPN in adult patients; Learn about indications for HPN in adult patients and clinical features (including prognosis) of these patients; Understand the importance of training and monitoring patients on home parenteral nutrition; Learn about common practice on training and monitoring; Learn about different central venous access devices (CVAD); Catheter related complications of infectious and mechanical origin; Strategy to prevent problems and treatment of complications; To learn about the feeding of the incurable cancer patient (why, which and how); To understand the impact of HPN on survival and quality of life; Withdrawing HPN; How to adapt nutrition support in HPN patients? What are the nutritional needs of a patient? How to cover the needs for a patient? How to evaluate PN dependence?; Learn about identifying the main metabolic HPN complications in adult patients; Learn how to prevent and cure these complications. Improvement of competencies and skills in CN, application of effective CN in the treatment of disease and health promotion, To acquire tools to interpret new scientific information, genetic predisposition and link with nutrition, better practical management of nutritional support.

Topic 20 Nutrition and Prevention of Diseases

To understand the potential of nutrition in cancer prevention. To understand specific behaviours that can modify cancer risk. To gather insights into the role of gene-diet interaction in determining response to dietary components.
To understand the mechanisms leading to osteopenia and osteoporosis. To appreciate the role of protein malnutrition in the development of osteoporosis. To understand the role of bone-muscle axis. To understand how to implement effective strategies for primary and secondary nutritional prevention of osteoporosis.
To understand the role of nutrition in the prevention of neurological disorders, focusing on the most prevalent neurodegenerative disorders. To understand the role of specific food components and nutrients in the prevention and course-modification of neurological diseases.
To understand that the risk for cardiovascular diseases (CVD) is closely dependent upon lifestyles. To understand the role of specific nutrients and food components in modulating the biochemical, molecular and genetic mechanisms underlying CVD.

Topic 21 Consequences of Diabetes on the Nutritional Status

Diabetes mellitus (DM) is a chronic metabolic disorder with disturbances not only of carbohydrate metabolism but lipid and protein metabolism as well. At diagnosis, Type 1 DM may be associated to malnutrition. However, Type 2 DM patients are generally obese and may have a relative reduction of fat free mass. Micronutrient deficiencies have been identified as risk factors for development of DM and poorer metabolic control, although therapeutic interventions have met variable success, depending on each individual micronutrient. When patients with stress hyperglycemia or DM require artificial nutrition, they may need the combination of insulin protocols and special formulas characterized by changes of the quality and/or quantity of carbohydrates and lipids, adjusting the energy provision to the nutritional requirements and metabolic control. The indications for specific formulas in diabetic patients are adjusted to the clinical setting and to the metabolic control achieved in the in individual patient.

Topic 22 Nutrition in Lipidaemias

Dyslipidemia (DL) is an important cause of atherosclerosis and cardiovascular disease. It can also cause pancreatitis and skin deposit of lipids. International scientific societies have issued clinical guidelines. The recommendations for diagnosis and management of these disorders may vary among them. It is advisable that health care providers choose the guidelines that better adapt to local cardiovascular risk and patterns of established disease. Along with statins and fibrates, new drugs have recently joined the therapeutic options for dyslipidemia such as antibodies to proprotein convertase subtilisin/kexin type 9, (PCSK 9), cholesterol ester transfer protein (CETP) inhibitors, antisense oligonucleotides and Inhibitors of the microsomal triglyceride transport protein (MTP). On the other hand, systemic inflammatory response is characterized by changes in lipid metabolism. When artificial nutrition is prescribed patients may experience lipid metabolism alterations due to primary lipid disorders or to the associated disease requiring special nutrition. Therefore, this prescription should carefully take into consideration lipid metabolism, as well as quality and quantity of lipids. Periodic laboratory checking will indicate the changes that may be needed to minimize these disturbances.

Topic 23 Nutrition in Obesity

Obesity is a chronic, systemic disease defined as a pathologically increased fat mass, which is associated with an increased health risk. A BMI > 30 kg/m2 is usually considered as a sign of obesity. Obesity requires a multidisciplinary and multimodal treatment, which varies depending on the phase of disease and the purpose (e.g. weight loss, weight maintenance). The treatment should be based on evidence. The goal of obesity therapy is to reduce the body weight in the long term in combination with a change in behaviour, which aims to improve obesity-associated risk factors, reduce obesity-related illnesses, reduce the risk of premature mortality, incapacitation and early retirement, and improve quality of life. Non-surgical lifestyle therapy comprises nutrition, exercise, behaviour change ("Basic therapy") which becomes more effective when combined with initial formula diet. Drugs can support obesity therapy, while other drugs can promote weight gain. The multimodal approach is the most effective non-surgical therapy resulting in a relative weight loss of 15-25%. A clear and realistic interface to bariatric surgery needs to be defined. Weight maintenance strategies including and beyond dietetic concepts are usually needed throughout life for long-term stabilization of body weight.

Topic 24 Nutritional Support in Metabolic Syndrome

The Metabolic Syndrome (MS) is a clustering of metabolic alterations including central obesity, hypertension, dyslipidaemia and hyperglycaemia. It carries increased risk of diabetes and long term cardiovascular disease (CVD), although short - term CV risk is better predicted by other means. Insulin resistance (IR) is a major underlying factor in the MS, with profound implications in terms of metabolic and CV morbidity.
Causes of IR are complex: altered adipose tissue endocrine functions, altered lipid metabolism also in non-adipose tissues, inflammation and oxidative stress are emerging as the key players. Important roles are also attributable to altered nutrient sensing in the gut and CNS. Measurement of IR with reliable surrogates provides an important tool for effective management of metabolic and CV risk in MS patients. Regarding therapeutic approaches, lifestyle modification improves diabetes and CV risk and is the first step in the treatment of MS. Modest weight loss and light physical activity significantly reduce IR. However, behavioral strategies are necessary to achieve long term success in maintaining adequate food intake and exercise. Finally, drug therapy of MS should address each of its components to prevent diabetes and CV disease and to reduce overall mortality. Metabolic effects and safety profile of each drug should be carefully considered.

Topic 25 Nutritional Support in Neurological Diseases

To identify different factors that may favour malnutrition in patients with neurological diseases. To understand the main characteristics of dysphagia and its relevance for nutritional support in patients with neurological diseases. To know the gastrointestinal consequences of neurological disease, relevant for nutritional support. To recognize the clinical consequences of malnutrition in patients with neurological diseases.
To know the deleterious consequences of energy and protein deficits in acute brain and spinal injuries. To know the most appropriate macronutrients needs: amount, time, and route. To know the reasons for undernutrition and the strategies to treat them.
To understand the most frequent reasons for nutrition in a stroke patient. To know the compulsory assessment leading to decision of nutritional support. To understand the respective indications of oral and enteral feeding, and the best enteral feeding route according to the clinical situation. To know the outcome of a stroke patient receiving enteral nutrition.
To know about nutritional intervention in patients suffering from Multiple Sclerosis or Parkinson's disease. To know the problems of clinical decision making in the timing/safety/efficacy of PEG tube feeding in amyotrophic lateral sclerosis patients. To understand the clinical challenge of establishing and maintaining a tube feeding in neurological patients with advanced dementia. To discuss the indications for gastrostomy in neurological patients with advanced dementia. To know the ethical, legal, and moral implications of nutritional support in patients with neurodegenerative disorders with progressive dementia.

Topic 26 Nutritional Support in Cancer

The aim of this topic is to provide a comprehensive overview of the clinical, societal and economic implications of malnutrition in patients with cancer. To this end, the difference between malnutrition and cachexia will be presented, as well as the phenotypic (i.e., anorexia, muscle loss, myosteatosis, etc.) and pathogenic (i.e., muscle and fat tissue catabolism, etc.) mechanisms leading to impaired nutritional status. Also, the putative mechanisms by which malnutrition reduces survival and impinges on quality of life will be discussed. The contributory role of anti-cancer therapies to the development of malnutrition will be also presented. The benefit of dietary counselling, as well as the indication for artificial nutrition will be presented, with a special emphasis on specific nutrients. A brief overview of innovative yet not validated dietary approaches to patients with cancer will be given (i.e., ketogenic diet, fasting, fasting-mimicking diets, etc.). The importance of physical activity and physical exercise integrating nutritional support will be addressed, and validated examples will be presented, highlighting benefits and limitations. Finally, the growing field of drug therapy of cancer cachexia will be discussed and how drugs may integrate nutrition support and anti-cancer therapies.

Topic 36 Nutrition in Older Adults

To understand the changes in body composition with ageing; To know the prevalence of undernutrition according to the subject's life setting; To know the factors contributing to undernutrition in the elderly; To know the main medical consequences of undernutrition; To know that elderly subjects are at risk for micronutrient deficiency; To know the recommended strategies for screening and assessing undernutrition; To know when and how to use nutritional supplements, and the results of this supplementation; To know the most frequent indications for artificial nutrition in the elderly; To know the techniques and outcome; To know the indications and results in specific clinical situations; To understand the need for ethical elements alongside the medical ones in deciding upon starting an elderly patient on artificial nutrition. Improvement of competencies and skills in CN, application of effective CN in the treatment of disease and health promotion; To acquire tools to interpret new scientific information, genetic predisposition and link with nutrition, better practical management of nutritional support. To understand sarcopenia, its causes, consequences, screening and interventions.

Topic 37 Nutrition and Sport

Explain the influence of exercise intensity, duration and mode, as well as of training status, diet and gender, on substrate utilization during exercise; Present the latest findings on the effect of physical activity and inactivity on ad libitum energy intake and on energy balance regulation; Clarify nutritional recommendations for endurance, strength and power sports; Discuss impact of physical activity on primary and secondary prevention of chronic diseases.

Topic 38 Nutritional Support in Pulmonary Diseases

To learn about the assessment and prevalence of nutritional depletion in in Chronic Obstructive Pulmonary Disease (COPD); To understand the importance of weight loss and nutritional depletion, the mechanisms, the consequences and reversibility of weight loss and muscle wasting in COPD; To develop an overview of the results of clinical trials of nutritional support in COPD; To understand the aims of nutritional support in COPD and how support programmes might integrate with other therapies; To understand the reasons why nutritional support programmes might be unsuccessful; To learn about the magnitude of the burden of the disease and the systemic involvement of chronic respiratory failure; To learn about the integration of nutritional support in pulmonary rehabilitation including exercise training for patients with systemic chronic inflammatory diseases as chronic respiratory failure. Improvement of competencies and skills in CN, application of effective CN in the treatment of disease and health promotion; To acquire tools to interpret new scientific information, genetic predisposition and link with nutrition, better practical management of nutritional support.

Topic 39 Let's talk about Nutrition: Communication Skills for Health Care Professionals

To undestand the available evidence-based effectiveness and efficacy of nutritional therapy in clinical practice. Define evidence to support the case of nutrition in the Health Care System.
To give a world overview of success and failures in recognition by Health Care System of the need of Nutrition Units/Support systems.
To understand that communication skills help to overcome barriers.
To acquire and practice communication skills to convince administrators, patients, lay people that nutrition plays a crucial and cost-effective role in disease prevention and treatment and in the prevention and treatment of disease-related nutritional disorders.

Topic 40 Presentation and Publication Skills

The educational need of this course is to understand how to write a project, to plan a study, to report the new data in a good quality paper, and to perform an adequate oral communication to meetings.
Upon the course, there will be a focus on the potential issues concerning research governance, on the pitfalls associated with research and publication.

Last modified: Wednesday, 4 May 2022, 8:16 PM