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Transversal Unit of Clinical Nutrition

Since 2008, the CHU Caen Normandie has had a Transversal Clinical Nutrition Unit whose main purpose is to detect and treat nutritional disorders in hospitalized patients. The UTNC is an operational team of clinical nutrition, with transversal functioning, intervening in all the CHU.

Within this unit, 2 expert structures are recognized:

  • Useful documents

    UTNC history (update 2021)

    • Missions

      What is a Transversal Clinical Nutrition Unit ( UTNC )?

      The National Nutrition and Health Plans ( PNNS ) have defined as priority objectives the detection and management of malnutrition in health establishments. One of the means proposed is in particular the establishment of a Transversal Clinical Nutrition Unit or UTNC ( PNNS 2006) which is also recommended within regional hospital centers by circular DHOS/E 1 n°2002-186 of March 29, 2002 relating to food and nutrition in health establishments.

      In 2007, the Department of Hospitalization and Organization of Care, on the basis of a call for projects, entrusted a steering committee with the selection of 8 experimental UTNCs They were created in March 2008 in the university hospitals of Caen, Lille, Lyon, Nancy, Paris (Joffre-Dupuytren and Necker), Rouen and Toulouse.

      The Ministry of Social Affairs and Health has published an educational summary on the transversal organization of nutrition within health and medico-social establishments: assessment of the UTNC experimentation ( 2008-2011) and proposals

      UTNCs are defined as transversal and multidisciplinary hospital structures coordinating clinical nutrition activities and whose main missions are the detection and management of nutritional disorders .

      This activity consists of ensuring:

      1. Nutrition-related care : hierarchical organization and coordination, dissemination of a culture of prevention and detection of nutritional disorders .
      2. Graduated specialist appeals and opinions
      3. Expertise relating to nutritional care (protocolization, quality policy, professional training, patient education, etc.)
      4. Participation in teaching
      5. Participation in clinical research in nutrition
      How is inpatient care organized?

      Schematically, the organization of clinical nutrition can be broken down into three levels: 

      Level 1: screening and adaptation of the food offer

      Actors: nurse, caregiver, doctor

      At this level, all patients benefit from:

      • nutritional screening (weight, height, weight change, construction of weight and height growth curves in children, BMI )
      • a food offering adapted to your state of health
      • traceability in the patient file

      The organization of screening for nutritional disorders requires

      • the participation of healthcare teams from care units.
      • the implementation of an intensive training strategy for health professionals.
      • the use of treatment protocols allowing autonomy in the management of the most common cases.
      • the traceability of information and interventions in medical mail which encourages coding in the hospital information system.

      Level 2: specialized care

      Actors: Dietitians

      It is aimed at patients with a nutritional disorder (undernutrition, etc.) requiring personalized care. At this level, the patients concerned benefit from:

      • a dietary diagnosis
      • personalized dietary support. The dietitian provides nutritional advice and participates in the education and nutritional rehabilitation of patients with nutritional disorders.
      • if necessary, referral to specialized obesity centers or health networks.

      The dietitian is called upon on medical request when the clinical situation requires it (inadequate food supply, risk assessment and analysis of the medical-surgical context and treatment possibilities) . He provides the medical and nursing team and the patient with the results of his nutritional assessment and his suggestions for dietary care.

      The decision on the most appropriate nutritional assistance (oral nutritional supplementation, enteral or parenteral nutrition) is made in consultation with the healthcare team and a nutritional care contract is drawn up with the patient including, if necessary, the outpatient continuation of treatment. charge.

      The dietitian is concerned with the nutritional quality of the diet offered to the patient, provides nutritional advice and participates in the education and nutritional rehabilitation of patients with nutritional disorders.

      The evolution of the activities of dieticians can be considered within the framework of cooperation between health professionals.

      Level 3: expert support

      Actors: Nutritionist doctor

      It is aimed at malnourished patients requiring enteral or parenteral nutritional assistance. At this level, the patients concerned benefit from:

      • a nutritional diagnosis and additional therapeutic advice
      • a proposal for nutritional assistance adapted to the functional capacities of the digestive tract.
      • an organization for outpatient care of nutritional assistance
      • regular nutritional monitoring in an outpatient setting or day or weekday hospital.

      For complex and/or severe situations, medical expertise and specific resources (specific biological markers, impedancemetry, calorimetry, functional tests) are requested allowing a detailed and personalized assessment of nutritional status.

      This expertise is necessary to initiate artificial enteral or parenteral nutrition (digestive tube, stoma, implantable chamber, catheter, etc.) , adapt nutritional intake to the pathology and implement therapeutic education for the patient and those around him in the care unit. This expertise is also necessary for long-term nutritional monitoring in order to ensure the good tolerance and effectiveness of artificial nutrition.

      Organized on an outpatient basis, this monitoring will be carried out in partnership with existing networks, service providers and the HAD.

      In pathologies of overweight or related to eating disorders, the use of multidisciplinary expertise including psychiatrists and psychologists trained in eating disorders ( TCA ) is essential.

      Importance of Physical Activity

      Physical fitness with respect to health is composed of cardiorespiratory (aerobic) capacity, muscular strength, muscular endurance, flexibility, balance and body composition. The decrease in the level of physical activity (PA) and the increase in sedentary behavior contribute to physical deconditioning and the accelerated deterioration of general condition.

      Nutrition and physical activity are essential pillars for maintaining and preserving health. Adequate nutrition goes hand in hand with appropriate physical activity.

       The practice of adapted physical activity ( APA ) by people suffering from nutritional disorders, cancer or even respiratory or cardiac disorders has numerous benefits, ranging from improving quality of life to reducing the harmful effects of treatments.

      Actors: Educator /Teachers in Adapted Physical Activity ( APA )

      The treatment is aimed at all patients who cannot join a sports structure and require the implementation or resumption of an adapted physical activity.

      The patients concerned benefit from:

      • an assessment of their physical conditions according to the four pillars of endurance, strength, flexibility and balance.
      • a therapeutic education workshop “move or not move”
      • a questionnaire “physical activity and you”
      • of an APA session
      • an orientation towards adapted structures thanks to the established regional network
      • the possibility also of treatment within the CHU, this is determined during the STAFF Nutrition or the Medical CPR

      APA support protocol consists of:

      • setting up a doctor, APA personalized APA program
      • APA program (6 to 12 weeks)
      • assessment of care (doctor, educator, patient)
      • renewal of the program or perpetuation of the APA with our partners (Prescri'sport Hérouville, Sport Santé Normandie, Planeth patient, etc.) .

      APA educator/teacher accompanies the patient and ensures remote monitoring throughout their journey, offering appropriate support at each stage (education, coaching, practical) and relaying the patient's needs to the various professionals. of the multidisciplinary team.

    • Nutritional pathologies

      Malnutrition

      Malnutrition is a deficit in energy (KCal) and protein, which leads to weight loss , with muscle wasting . The consequences are a decrease in immune defenses (fight against infections) , a delay in healing, and in general, an increase in the duration of hospitalization.

      To detect malnutrition , it is necessary to know the BMI and the weight loss of the hospitalized person.

      Dietitians are on the front line in care units to manage malnutrition, in collaboration with doctors.

      Doctors from the Nutrition Unit intervene to give specialist advice in complex nutritional situations. They provide consultation for malnourished patients with medical problems related to malnutrition, for example:

      • sequelae of digestive surgery,
      • neurological pathologies,
      • ENT pathologies ,
      • celiac disease,
      • vitamin or mineral deficiencies without established cause…

      The treatment for malnutrition is as follows, depending on the degree of malnutrition:

      1) Adaptation of oral diet

      => enrichment of dishes and fractionation and/or addition of specific high-calorie and high-protein foods (Oral Nutritional Supplements CNO),

      2) or artificial nutrition (by digestive or venous route)

      Artificial nutrition consists of providing a balanced nutrient solution adapted to the body's needs.

      There are two routes of administration: the digestive route (enteral nutrition) and the venous route (parenteral nutrition).

      • The enteral route (via the digestive tract) is preferred because it is more effective, more physiological and less risky.
        It can be complementary to an insufficient or exclusive oral diet if feeding is impossible. Enteral nutrition is administered either through a naso-gastric tube (a very thin, flexible, small-calibre tube) which enters a nostril and goes directly into the stomach, or through a gastrostomy tube (a tube in the abdominal wall ) placed in the operating room. Enteral nutrition is carried out with nutrient mixtures in ready-to-use pouches.
      • (venous) nutrition is prescribed when oral (by mouth) or enteral (through a tube) nutrition is impossible, insufficient or poorly tolerated
        Parenteral nutrition is given into a vein through the via a catheter positioned either on the forearm (Picc-line), or below the clavicle (central catheter), or on the thorax (implantable port).
      intestinal failure

      Intestinal failure is a rare disease, the most common cause of which is short bowel syndrome following extensive bowel resection surgery. The intestine is no longer able to absorb nutrients.

      These patients therefore require long-term parenteral nutrition at home, and most often for life. The NPAD makes it possible to bring intravenous nutrition to the home covering water, ionic and nutritional needs, while preventing potentially serious complications: infections, liver diseases, osteoporosis, etc.

      Norman establishments who are experts in the NPAD have decided to join forces to create a university center for NPAD in Normandy, bringing together the skills that exist in the region. This center was certified in 2020 by the DGOS (12 adult centers in France) . It associates the CHU of Rouen, CHU of Caen and the SSRs of the CH of the Côte Fleurie and the Bois Guillaume Red Cross.

      It is based on 3 pillars:

      1. Optimization of the gradation of care and patient pathways
      2. Decompartmentalization and homogenization of care
      3. Pooling of training and research actions

      The Norman establishments wished to rethink the regional organization by associating the University Hospitals which take care of patients in the phase of acute intestinal insufficiency and the specialized SSRs which provide rehabilitation and therapeutic education during the transition to the chronic phase, and making the patient journey more fluid.

      NPAD over 3 months old in an expert center, while that the historic centers mainly took charge of NPADs of very long duration > 1 year.

      The referents for the Center are as doctor, Pr Marie-Astrid Piquet (CHU Caen Normandy) and as pharmacist, Dr Aude Coquard (CHU Rouen Normandy) .

      Metabolic diseases

      Metabolic diseases are pathologies caused by a disturbance of the enzymatic pathways of synthesis or degradation of molecules in the body (an enzyme is missing or an amino acid is missing, etc.) .

      They can be acquired (diabetes, obesity, etc.) or innate. Inborn errors of metabolism are genetic diseases caused by the mutation of a gene coding for one of these enzymes. Symptoms result either from an accumulation of toxic substances upstream of the enzymatic deficiency or from a lack of synthesis of essential products downstream which cause serious consequences for development.

      There are four categories of diseases:

      • intoxication diseases : phenylketonuria, leucinosis, urea cycle deficiency galactosemia, tyrosinemia, fructosemia, homocystinuria, Wilson's disease, porphyria, Lesch-Nyhan….
      • energy diseases: glycogenosis, mitochondrial cytopathies, fatty acid betaoxidation abnormalities, gluconeogenesis deficit, Krebs cycle deficit, creatine metabolism deficit,….
      • storage diseases: lysosomal and peroxyzomal diseases….
      • other: protein glycosylation abnormality, neurotransmitter metabolism abnormality, sterol abnormality

      The clinical picture varies according to the organs affected by these enzymatic deficiencies and the age of revelation. It can be an isolated attack of an organ (cystinuria for example) but most often it is about multisystem attacks affecting in particular the central nervous system and the liver.

      Current treatments are based on different types of diet, vitamin supplements and taking purifying medications.

      For patients with phenylketonuria, there have been recent developments that require extending their care throughout adult life, whereas previously the follow-up was stopped at around 18 years of age.

      The adult and pediatric departments of Caen Normandy University Hospital work in close collaboration with the Metabolic Diseases laboratory .

      A multidisciplinary consultation can be proposed to make a medical, dietary +/- psychological and social assessment.

      Obesity

      Obesity, considered a chronic disease, results from an imbalance between energy intake and expenditure . This imbalance leads to an accumulation of reserves stored in fatty tissue.

      Obesity corresponds to an excess of fatty mass and to a modification of adipose tissue which have harmful consequences for health .

      The etiology of common overweight and obesity (as opposed to secondary obesity) is complex and multifactorial . Many factors, modifiable or not, have been identified as being associated with overweight and obesity: genetic and biological, psychological, socio-cultural and environmental factors, including diet and physical inactivity.

      The clinical diagnosis of overweight and obesity involves in particular the calculation of the Body Mass Index, a method which remains to this day a simple means of estimating the fat mass of an individual. BMI is the weight (in kg) divided by the square of the height (in meters) . According to the WHO classification, we speak of overweight from a Body Mass Index of 25 kg/m² and obesity from a BMI of 30 kg/m².

      However, the BMI gives an approximate indication because it does not necessarily correspond to the same degree of adiposity from one individual to another.

      In children , it is necessary to refer to the growth curves present in the health records.

      Another criterion is also taken into account to estimate whether a patient is obese: waist circumference or abdominal circumference. Excess fat in the abdominal region (fat around the viscera) is indeed associated with an increased risk of diabetes and cardiovascular disease, but also of certain cancers, independently of BMI.

      When the waist circumference is greater than or equal to 94 cm in men and 80 cm in women (outside of pregnancy) , we speak of abdominal obesity.

      Obesity is currently a public health problem in the world and in our country. It reaches 17% of the French population, and 19.8% in Normandy (according to the OBEPI-ROCHE 2020 survey) .

      The consequences of obesity are an increased risk of various pathologies (including cardiovascular diseases, diabetes, certain cancers) , as well as infertility problems and osteo-articular pain...

      The CHU Caen Normandie Specialized Center for Obesity 37 French expert centers in the management of severe and/or complex obesity.

      Overweight is no indication for hospital treatment. Overweight is managed by the attending physician. International recommendations emphasize the need to stabilize weight, through regular physical activity and a balanced diet.

      Eating Disorders

      Eating disorders are eating behaviors different from those usually adopted by people living in the same environment. These disorders are significant and long-lasting and have psychological and physical repercussions.

      Anorexia nervosa
      It is characterized by a restriction of food intake leading to a significant loss of weight associated with an intense fear of gaining weight. The person suffering from anorexia nervosa has the feeling of being always overweight and tries to lose weight by all means. This includes controlling the calories of all food consumed. The person has a disturbed perception of the image of his body and does not recognize the seriousness of his thinness.

      Anorexia nervosa may be associated with bulimic behavior.

      This obsession with weight loss under the influence of psycho-behavioral factors makes anorexia nervosa a psychiatric pathology requiring specific treatment.

      HAS recommendations

      Bulimia and binge eating
      It is characterized by crises during which the person compulsively absorbs large quantities of food, in a short time, at any time of day or night. These binges are associated with a feeling of loss of control and are followed by inappropriate compensatory behaviors such as self-induced vomiting, use of laxatives, diuretics, fasting between attacks, and excessive exercise. People with bulimia have a loss of self-esteem and are not overweight due to compensatory measures.

      We speak of binge eating when recurrent episodes of bulimia attacks are not associated with compensatory behaviors (vomiting, use of laxatives, etc.) . In general, binge eating causes overweight or obesity and generates psychological suffering.

      HAS recommendations

      Follow-up in consultation of anorexic or bulimic adults is provided by psychiatrists, who refer the nutritional aspect to the nutrition department.

      In pathologies related to eating disorders, the use of multidisciplinary expertise is essential including adult doctor/paediatrician, dietitian, educator in adapted physical activity, psychiatrist and/or psychologist trained in eating disorders.