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Kathrine Grigsby, RD, LD
University of Alabama-Birmingham Hospital

katherine grigsbyIn years past, I have often shunned the covenants to self, those so-called "resolutions," that without fail have always left me feeling guilty, defeated, and craving whichever vices I have vowed to give up. But unlike years past, 2012 marks the beginning of a resolve that goes beyond kicking my own personal bad habits. This year is about prioritizing the health and nutrition status of my adult acute care patients. Much like a new year, one's health and nutrition will often be what is made of it, and the heart and lung transplant patient population is no different. With appropriate guidance and fresh, creative takes on diet and nutrition, both pre- and post-transplant individuals may find themselves with a renewed sense of commitment and determination to maintain compliance with their dietary specifications.

While a comprehensive nutritional evaluation is helpful among any group, for the chronically ill and sometimes frequently hospitalized transplant service patients, a thorough dietary assessment and nutrition care plan is a necessary facet of care. Though the nutritional needs can vary as much their symptoms, transplant patients at risk for malnutrition often present as one of two extremes: underweight or obese.

Designated by a BMI ≤18.5 kg/m2, the underweight patient is often found to have a greater incidence of poor outcomes including abnormal immune function, muscle atrophy, impaired wound healing, increased length of stay and mortality. While weight gain, increases in lean body mass, and improvements in visceral protein status are the obvious goals for these nutrient-deficient individuals, identifying manageable solutions for their struggles is the real challenge.

Upon initial assessment, tell-tale signs of suboptimal diet history emerge with patient reports of "poor appetite," "unintentional weight loss," and "altered taste," all commonly occurring as a result of medication regimens, fluid gains, and GI disturbances. In the clinical setting, obtaining a brief diet recall will open doors to educate patients about possible areas of improvement in their diets—a lower sodium diet for the fast food-aholic, tips on curbing thirst for the volume overloaded, and examples of protein rich foods for the protein-calorie malnourished. Spend time finding out your patient's food preferences, and use that as a baseline to build a modified diet. Set up taste tests with appropriate oral supplements and allow them their own choice, remembering that taste buds can change and some individuals will need variety. (Side note: Remember that what works for one patient may not work for the next. I can recall feeling terrible one afternoon when a CF patient of mine explained to me that she couldn't tolerate the taste of vanilla-flavored supplements anymore because they so resembled the odor of the gas that came up in the mornings after receiving nocturnal tube feedings. Can you imagine being force-fed something that reminded you of that?) Stress the big picture value of consuming adequate protein and calories, explaining to the patient with a poor appetite the importance of first filling up on nutrient-dense items like lean meats, dairy, and whole grains. And finally, always liberalize when medically able. Encouraging a patient who is 60% IBW to eat more protein-rich foods won't go too far if their cardiac prudent diet prohibits them from a variety of meat and dairy choices; sometimes picking the lesser of two evils is necessary in order to maximize a patient's nutrient intake, at least until adequate intake is established and weight is within normal limits.

At the other end of this spectrum are the obese who, with a BMI ≥ 30, are at increased risk of morbidity and mortality. When assessing this group, obtaining an accurate weight history is helpful in determining their true nutrition status. For example, a male with a BMI of 40, consistent weight gain over five years, and excessive eating habits will require a much different type of nutrition therapy than a weight- and height-matched individual who has experienced unintentional weight loss of 85 pounds over a three month period of time. Much more information can be derived from talking to a patient about their history, so personal communication is the first step toward improved outcomes.

An obese patient who is pre-transplant will almost always benefit from healthy, monitored weight loss prior to transplant and are then less likely to experience an adverse event during/after surgery. Find out first how they got to their current weight—physical inactivity, emotional eating, or financial constraints that left them limited to purchasing high fat, high sugar convenience foods—and help them to understand how their weight is affecting their health. (You would be stunned to know how often I look into the eyes of a bewildered CHF patient who can't believe that his heavy salt-shaking hand and potato chip addiction has contributed to the 15 pounds of fluid sitting on his belly!) Next, find out what motivates that patient—whether it be getting an organ transplant or making it out of the hospital to see their grandkid's piano recital—and use that to stimulate their desire for weight management. Set short-term, attainable goals, designed to be achieved over time to ensure that weight is lost appropriately and in such a way that will not cause them further harm.

Once post-transplant, weight control is imperative in controlling co-morbidities like diabetes, hyperlipidemia, hypertension, osteoporosis, and infection. Excessive weight gain after transplant increases risk of rejection and decreases rate of survival, thus nutrition intervention requires individualized care, combining disease specific diet restrictions with the provision of ample calories and protein. Management of symptoms like nausea, pain, constipation, and diarrhea often results in increased energy and appetite, enhancing the willingness of patients to participate in post-operative nutrition therapies. Comprehensive education, followed by patient participation in setting their own dietary goals, improves long-term compliance and imparts a tremendous sense of pride for patients who succeed in accomplishing their objectives.

Unlike personal New Year's goals that so easily dwindle to oblivion, improving the nutrition status of transplant patients is one resolution that is worth keeping. This is a New Year's resolution in which we all share in the success.

Disclosure Statement: The author has no conflicts of interest to disclose.