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Medical Nutrition Therapy in

Crohns Disease Patients

University of Maryland, College Park Dietetic Internship
Anastasia Maczko

Table of Contents
I. Executive Summary.............3
II. Case Report..............4
III. Hospital Course of Patient...........6
IV. Case Discussion.............10
V. Appendices................12
VI. Glossary.............14
VII. References.................15

Crohns disease (CD) is described as inflammation of the digestive tract, anywhere from the
mouth to anus. CD is categorized as a type of inflammatory bowel disease, along with ulcerative
colitis, which is limited to the large intestines and colon. CD is characterized by abscesses,
fistulas, mucosal thickening, narrowing segments of the bowel and partial or complete
obstructions of intestines.1 The etiology of CD is not specifically known and a combination of
clinical judgment, biological laboratory values, and endoscopy/CT scans is used to diagnose
these patients. CD is often hereditary and can increase ones chances of acquiring the disease,
however, because the effect of genetic and environmental factors is unclear, hereditary
involvement is unknown. Patient symptoms of the disease range from relentless diarrhea, rectal
bleeding, abdominal pain, or constipation during a flare up, to no signs and symptoms at all for
months or even years.1
Malnutrition in patients who experience frequent Crohns flare ups is common due to decreased
appetite, nausea, abdominal pain, altered taste buds, decreased absorption related to the intestinal
inflammation, and need for increased energy/protein intake during a flare up. Many patients and
health professionals believe that certain foods or special diets aid in the repair of Crohns
inflammation, however, no conclusive research supports any one specific diet. Treating CD from
a nutrition perspective varies person to person regarding which specific foods may irritate the
gastrointestinal tract of that individual. The ultimate goal of the dietitian is to maximize oral
intake to prevent malnutrition and dehydration. Some patients may experiment with lowfiber/residue diets to decrease pain when defecating or limit intake of fried foods to delay gastric
emptying and control diarrhea.
In patients who experience frequent flare-ups leading to multiple bowel resections, nutrition
therapy is often necessary to ensure patient receives adequate nutrition. Patients with CD who
are unable to meet their energy/protein needs through oral intake and supplements may require
enteral or parenteral nutrition. Enteral nutrition is often the primary therapy used to treat CD to
help maintain gastrointestinal (GI) integrity via continuous feeds rather than bolus, reducing
complication risk.2 Parenteral nutrition is often used when physicians recommend bowel rest
or those with persistent bowel obstructions, however, no sufficient evidence has been released
proving parenteral nutrition is more beneficial than enteral nutrition.2 Parenteral nutrition is often
favored in patients with short bowel syndrome and those who are intolerant of enteral feedings.3
Not only are patients diagnosed with CD at risk for macronutrient deficiency, but also
micronutrients, vitamins and minerals. Consequential clinical syndromes may include anemia,
osetomalacia, peripheral neuropathy, night blindness, and glossitis.2

General Information
ZZ is a 47-year-old Caucasian male admitted to MedStar Union Memorial Hospital in Baltimore,
Maryland on October 2, 2014. The patient has a 30-year history of CD, beginning when he was
operated on at the University of Maryland Medical Center at the age of 17 with an ileo-ascending
colectomy and anastomosis. The patient regularly checks up with his primary care physician
every 6 months. The patient called his primary care physician (PCP) complaining of abdominal
pain, persistent cough, postnasal drip, fever, and chills one week prior to admission and was
started on Cipro and Flagyl. ZZ was sent for an abdominal CT scan revealing small pockets of
abscess inflammation and was admitted to the hospital for Crohns flare up. The patient was
discharged home with total parenteral nutrition (TPN) on October 11, 2014 and follow up
scheduled with primary care physician for repeat CT scan.
Social History
The patient resides in Pennsylvania with wife, does not have any children, and is a fulltime
employee at Lowes and has Blue Cross Blue Shield health insurance. ZZ has no family members
with a history of inflammatory bowel disease. Patient has a history of (h/o) smoking one pack
per week for over 20 years, but has since quit for the past 2- years. ZZ reports occasional
alcohol consumption on the weekend including 6-10 beers. Patient does not have a history of
drug abuse, nor does he have a family history of drug abuse.
Medical/Surgical Data
Past Medical History
Crohns disease. No family history of inflammatory bowel disease.
Past Surgical History
Patient underwent an ileoascending colectomy at age 17. Anastomosis was performed.
Admitting Physical Exam
Patient is a healthy 47-year-old male, no acute distress present on admission. Patient reports 101102 Fahrenheit fever prior to admission. Patients abdomen was slightly distended and tender in
the left lower quadrant area of the abdomen. Abdominal exam reveals a diastasis recti, possible
hernia. Patient is overweight with a BMI of 29.
Surgical Procedures since Admission
No surgeries were performed during ZZs admission.
Laboratory Results
Refer to Appendix A for laboratory results during this hospitalization.

Refer to Appendix B for complete lists of home and in-patient medications.
Diagnostic Tests with Results
October 2
October 2

Diagnostic Test
Abdominal CT (outpatient)
Chest X-ray

Active inflammation with fluid levels.
Lung well ventilated, no infiltrate or area of
consolidation. No acute cardiopulmonary
October 7
Abdominal CT
Thickened distal ileum with hyperemia,
fistulous tracts between small bowel loops and
multiple small areas of abscess identified.
Diastasis recti with two hernias containing fat
are asymptomatic at this time.
October 8
Chest X-ray
PICC line placement, PICC tip at the low SVC.
* Per radiologist, patients CT scan improved compared to previous outpatient abdomen CT.
Food Allergies
Patient has no known food allergies.
Nutritional History from Initial Encounter
Diet History
ZZ adheres to a regular, healthy diet at home. ZZ reports no trigger foods, allergies, or
intolerances related to Crohns flare up. Patient had poor appetite one week prior to admission,
but ate 100% of meals during hospitalization, despite receiving clear liquids only. ZZ has not
been previously admitted to hospital.
Weight History
ZZs ideal body weight (IBW) based on the Hamwi equation is 180 pounds. ZZ reports usual
body weight is 220 pounds and has not changed in the past five years.
October 3
October 5
October 8

220 lbs
220 lbs
218 lbs






29 (overweight)
29 (overweight)
29 (overweight)

Physical Activity Level

Patient reports he is active during his job at Lowes, standing for several hours. Patient was nonambulatory during hospital stay. Patients TPN was cycled prior to discharge to allow greater
freedom at home.
Estimated Nutrient Needs

Facility standards
Online nutrition care

Kcal requirements
2,187-2,417 kcals
(Mifflin St Jeor)
2,187-2,417 kcals
(Mifflin St Jeor)

Protein requirements
100 g protein (1.0

2,500 kcals (25


100-150 g protein
(1.0-1.5 g/kg)

Fluid requirements
1,296-2,495 mL (2025 mL/kg)
2,187-2,417 mL
(Adolph Method 1
2,187-2,417 mL
(Adolph Method 1

Intake of Vitamins/Minerals, Oral Liquid Supplements and/or Alternative Supplements

ZZ did not utilize or consume any vitamins/minerals, oral liquid supplements and/or alternative
supplements prior to admission. Patient was initially NPO upon admission. Patient began on a
clear liquid diet and received Ensure supplements three times a day. Patient advanced to PSS
nutrition support and received clear liquid diet without supplements. Patient switched to TPN
nutrition support and NPO status.
Cultural Attitudes that Influence Dietary Intake
Past/Present Dietary Regimen/Nutritional Therapy



Clear Liquid
Clear Liquid


Modifications Intake






Ensure Plus
PSS, Ensures


Hospital Course of Patient

Medical Treatment
v Day 1 (10/2/14) Patient sent to emergency room by primary care physician for flare up of
Crohns disease. Outpatient CT scan revealed active inflammation with fluid levels. ZZ
complained of nausea, vomiting, abdominal pain, and diarrhea. Patient admitted to
MedStar Union Memorial Hospital and started on methylprednisolone. Diet: NPO
v Day 2 (10/3/14) Patient started on a clear liquid diet with Ensure Plus supplements three
times per day. Diet: CLD (100% consumption), Ensure TID (100%).

v Day 3 (10/4/14) Patient began PSS in addition to clear liquid diet order. Ensure
supplements discontinued. Diet: CLD (100%), PSS.
v Day 4 (10/5/14) No changes recorded in patients chart. Diet: CLD (n/a), PSS.
v Day 5 (10/6/14) A PICC line was placed for patient to begin TPN and antibiotics for a
minimum of 14 days outpatient. Diet: CLD (100%), PSS
v Day 6 (10/7/14) Patient discussed in rounds, gastrointestinal (GI) team recommend CT
enterography in afternoon. Patient is on day four of PSS. Diet: CLD (100%), PSS
v Day 7 (10/8/14) CT scan showed small areas of abscess and gas identified medial to
diseased distal ileal segment; fistula tracks to small bowel and colon were noted. Growth
has decreased slightly in past week. Diet: CLD (100%), PSS
v Day 8 (10/9/14) GI recommends repeat CT in five days. CT scan showed abdominal
abscesses and fistulous tracts. Patient NPO and began TPN. Patient continues intravenous
(IV) Cipro, IV Flagyl, and IV steroids. Social work working with home health to arrange
at home TPN arrangements. Diet: NPO, TPN (half goal rate)
v Day 9 (10/10/14) Patient not at TPN goal rate at this time. Patient TPN to be cycled prior
to discharge. Patient to be sent home on TPN with home IV Flagyl and Cipro. Diet: NPO,
TPN (half goal rate)
v Day 10 (10/11/14) Patient discharged to home in Pennsylvania with TPN set up at home.
Patient will need repeat abdominal CT enterography in five days. Patient will follow-up
with PCP on 10/30/2014. Diet: NPO, TPN (goal rate).
Nutrition Treatment
Initial Assessment 10/03/14
Nutrition Assessment:
Age: 47 y/o
Gender: Male
Weight: 99.8 kg, 220 lb
Height: 184 cm, 60
IBW: 178 lb
UBW: 220 lb
%UBW: 100%
BMI: 29 (overweight)
Ileoscending colectomy (1984)
Crohns Disease diagnosed (1984)
Abdominal pain
Softer stool
Persistent cough, postnasal drip

Labs: See Appendix A for all laboratory

results during visit.
Prednisone (steroid)
Flagyl (antibiotic)
Zosyn (antibiotic)
Heparin IV (blood thinner)
Pantoprazole (protonix)
Current Diet
10/03/14: Clear Liquid Diet + Ensure Plus

Diet History
NPO x 1 day
Normal, healthy diet, eats all food groups.
No intolerances, allergies, or Crohns
specific foods.
Nutrition Diagnosis Initial Assessment 10/03/14
NC-1.4: Altered GI function related to compromised function of GI tract as evidenced by
Crohns disease flare up and bowel inflammation via abdominal CT scan.
NI-5.3: Inadequate protein, energy intake related to restricted po intake as evidenced by
current clear liquid diet order not meeting patients energy needs.
Nutrition Intervention Nutrition prescription, Interventions with goals
Nutrition Prescription
Intervention with goals
2,187-2,417 kcal (Mifflin St Jeor), 100 g
RC-1.4: Collaboration with other
protein (1.0 g/kg), 1,996-2,495 mL (20-25
providers: Recommend advance diet to GI
soft or nutrition support within next 1-2
ND-2.2.5: Parenteral Nutrition: Insert route
for PSS (protein sparing solution) to being
within next 1-2 days (2400 mL bag
providing: 80 g dextrose/day, 68 g
protein/day, 89 g lipids/day)
Nutrition Monitoring and Evaluation
F-1.1.1: Energy Intake
F-1.5.2: Protein Intake

Consumes 50% of energy needs orally
within 2 days.
Consumes 50% of energy needs orally
within 2 days.

Follow-up 10/06/14
Nutrition Diagnosis Follow-up 10/06/14
NC-1.4: Altered GI function related to compromised function of GI tract as evidenced by
Crohns disease flare up and bowel inflammation via abdominal CT scan.
NI-5.3: Inadequate protein, energy intake related to restricted po intake as evidenced by
current clear liquid diet and PSS not meeting patients energy needs.
Nutrition Intervention Nutrition prescription, Interventions with goals
Nutrition Prescription
Intervention with goals
2,187-2,417 kcal (Mifflin St Jeor), 100 g
RC-1.4: Collaboration with other
protein (1.0 g/kg), 1,996-2,495 mL (20-25
providers: Recommend advance diet as
medically feasible per MD.
ND-2.2.4: Parenteral Nutrition: Continue
PSS x 5 days.

ND-2.2.5: Parenteral Nutrition: Insert
PICC for TPN (total parenteral nutrition) to
begin within 1-2 days.
Nutrition Monitoring and Evaluation
F-1.1.1: Energy Intake
F-1.5.2: Protein Intake

Consumes 50% of energy needs orally
within 2 days.
Consumes 50% of energy needs orally
within 2 days.

Follow-up 10/08/14
Nutrition Diagnosis Follow-up 10/06/14
NC-1.4: Altered GI function related to compromised function of GI tract as evidenced by
Crohns disease flare up and bowel inflammation via abdominal CT scan.
NI-5.3: Inadequate protein, energy intake related to restricted po intake as evidenced by
current NPO diet order for bowel rest 2/2 Crohns Disease and PSS not meeting patients
energy needs.
Nutrition Intervention Nutrition prescription, Interventions with goals
Nutrition Prescription
Intervention with goals
2,187-2,417 kcal (Mifflin St Jeor), 100 g
ND-2.2.3: Parenteral Nutrition: Initiate
protein (1.0 g/kg), 1,996-2,495 mL (20-25
TPN bag within 24 hours.
Bag #1 60 g pro, 527 kcals CHO, 283
kcal lipids, total volume 1080 mLs, rate 45
Bag #2 If patient tolerate bag #1 of TPN,
order TPN at goal for bag #2. 120 g pro
(1.2 g/kg), 1053 kcals CHO (2.16
mg/kg/min), 567 kcals lipids (0.57 g/kg),
total volume 2160 mLs, rate 90 mL/hr.
RC-1.4: Collaboration with other
providers: work with primary care
physician to cycle TPN bag prior to
discharge and home health care.
Nutrition Monitoring and Evaluation
FH-1.3.21: Parenteral Nutrition

Discontinue PSS and initiate TPN orders.


Case Discussion
Medical Considerations
The pathophysiology of Crohn's Disease itself is still being researched, however, based on recent
findings CD involves irregular inflammatory responses similar to an autoimmune disorder due to
overactive T-cell responses of enteric bacteria. Inflammation or abscesses that began in the
intestines may have been minuscule initially, however, increased inflammatory response to the
area can cause wall thickening and potentially lead to bowel obstructions. In 2006, Nature
Journal suggests that several key factors make up the likelihood of chronic intestinal
inflammation including: genetic susceptibility, environmental triggers, immune response, and
luminal microbial antigens.
Genetics research is still being developed, but according to the Nutrition Care Manual, 21 genes
have been identified for Crohns disease and promotion of inflammation.4 Environmental factors
that may have contributing effects include antibiotic use, NSAIDs, stress, diet and smoking
especially, can initiate onset or reoccurrence of the disease, interfering with the mucosal lining.4
Antibiotics have been shown to be successful in patients with CD, paired with probiotics patients
can improve the amount of time between relapses.
TH1 and TH17 are the major cytokines dominant in Crohn's patients.5 These receptors are
responsible for macrophage activation and release inflammatory cytokines, which further
increase inflammation. TH1 cytokines are specific to Crohns disease, while TH2 is specific to
Ulcerative Colitis, TH 17 cytokines have been recurrent in journal articles recently for their
proinflammatory abilities.6 Normally, when trauma or inflammation occurs, the immune system
responds and then turns off its response. In IBD patients, the increase exposure causes a
decrease in restraining ability of the inflammatory response attack it repeatedly damaging the
GI tissue.1
Nutrition Therapy
ZZ was admitted to the hospital after prolonged decreased appetite, fever, and GI
symptoms including nausea, diarrhea, and abdominal pain. ZZ contacted his PCP, whom he
follows up with every 6 months. His PCP prescribed him Cipro and Flagyl antibiotics to see if
symptoms subsided. One week later, ZZ traveled from his home in Pennsylvania to Baltimore,
Maryland to meet with PCP and have an outpatient abdominal CT scan. The CT scan showed
small pockets of abscess inflammation and the patient was sent to MedStar Union Memorial
Hospital for bowel rest and further treatment. ZZs recorded weight upon admission was 220
pounds and ZZ reported consistent with his typical weight for the past four years. Based on the
facilities standards for determine energy and protein needs the following was calculated: 2,1872,417 kcals, 100 g protein, and 1,996-2,495 mL fluids.
The patient initially was NPO upon admission for the first 24 hours for testing, before a clear
liquid diet was initiated. The patient requested additional food and Ensure Plus was provided at
each meal to increase energy intake and still provide some bowel rest. The patient reported GI
symptoms had subsided and appetite was and patient felt "back to normal" within the first 48
hours. The patient was becoming restless and was ready to eat solid foods. The family had
recently come back from a trip to South Carolina and reported no unusual foods consumed or
unusual stressors in the patient's life. The patient, at the age of 47, has not had a Crohn's flare up

since he was 17 years old and first diagnosed. The patient reports eating a well rounded diet and
does not find that certain foods upset his stomach more so than others (i.e. nuts, spices). Patient
does not have any allergies.
The medical team decided to begin PSS for this particular patient to meet his nutritional needs
until a more definitive plan of care was established. The patient continued PSS for five days
before the clear liquid diet was discontinued and the patient would begin TPN. ZZ met his goal
rate and the patient was to be cycled before being discharged home to provide maximal mobility
and quality of life while receiving TPN. The patient was discharged with TPN, IV Cipro, IV
Flagyl, prednisone, protonix, and fluctinase for his persistent cough. ZZ would return to his PCP
in 4 weeks to have a repeat CT scan performed.
Nutritional Implications to the Dietetic Practice
Inflammatory bowel disease includes both Crohns disease and Ulcerative colitis, both of which
lead to increased risk of malnutrition and potential for malabsorption issues. Beginning patients
with a current flare on clear liquid diet is key to allowing some bowel rest. The patients diet
should slowly progress to low-fat, low-fiber, high-protein, and high-calorie meals as medically
feasible to reduce symptoms. Fiber restriction is only necessary when acute exacerbations are
present. As the patient heals, fiber may gradually be added to the diet. In addition, the patient
may or may not need to begin a multivitamin regimen if they are unsuccessfully meeting their
nutritional needs.
Nutrition support is necessary in patients that are unable to meet their needs for an extended
period of time orally. Depending on the functionality of the GI system, enteral nutrition provides
greater benefits and decreased risk than total parenteral nutrition. With this patient specifically,
enteral nutrition may not have been beneficial due to fistula development. The patient proved to
be a candidate for total parenteral nutrition until inflammation subsided. Patients with short
bowel syndrome may benefit from parenteral nutrition more than enteral nutrition. After reading
several journal articles, it seemed clear the right method of nutritional support would be enteral
nutrition, however, total parenteral nutrition was selected to allow total bowel rest. Nutritional
intervention is important in preventing the patient from developing deficiencies and essential in
maintaining GI integrity.7
Dietitians play a crucial role in working with the patient to go through a 24-hr recall or food
history to decide which foods may have potentially been triggers. In the case of this patient, he
has not had a flare-up in 30 years and does not exclude certain foods from his diet. It is important
that when working with Crohn's disease patients that we limit the foods excluded from a
patients diet as much as possible to maximize oral intake. Telling patients to eliminate certain
foods or food group may cause an unnecessary increase in malnutrition. An estimate 60-75% of
patients with CD experience malnutrition4.
Given the nature of the disease, many clients will look at alternative therapies that the Registered
Dietitian needs to understand and ask the client about during the interview. These therapies
include nutrition supplements (Zinc, Folic acid, B12, Vitamin D, Calcium, Omega-3 fatty acids,
probiotics, n-acetyl glucosamine, glutamine), herbal medications (slippery elm, marshmallow,
curcumin/turmeric, cats claw, boswellia), homeopathy (mercurius, podophyllum, veratrum
album) and acupuncture.8 This patient specifically, only enforces the need for increased research
related to inflammatory bowel diseases. ZZ did not fall in the categories for people with an

increased risk of developing Crohns disease, but may have an underlying genetic quality that is
still unknown.

Appendix A: Laboratory Results
Sodium Lvl


Potassium Lvl


Glucose Lvl
Calcium Lvl
Magnesium Lvl
Phosphorus Lvl


8.9 mg/dL
2.0 mg/dL
3.4 mg/dL

8.7 mg/dL
2.1 mg/dL
4.0 mg/dL

8.7 mg/dL
2.1 mg/dL
4.2 mg/dL
80 mg/dL
35.9 mg/dL

9.5 mg/dL
2.3 mg/dL
4.2 mg/dL
162 mg/dL
31.8 mg/dL

9.0 mg/dL
2.2 mg/dL
4.4 mg/dL







Sodium Lvl


9.4 k/uL
12.7 gm/dL
140 mmol/L

10.0 k/uL
13.0 gm/dL
139 mmol/L

13.2 k/uL
13.7 gm/dL
137 mmol/L

11.3 k/uL
14.5 gm/dL
138 mmol/L

Potassium Lvl


3.6 mmol/L
106 mmol/L

3.6 mmol/L
103 mmol/L

4.4 mmol/L
102 mmol/L

3.6 mmol/L
103 mmol/L

Glucose Lvl
Calcium Lvl
Magnesium Lvl
Phosphorus Lvl
Total Protein
Bili Direct
Albumin Lvl
Bili Total
Alk Phos


9.4 k/uL
13.2 gm/dL
3.5 mmol/L
27 mmol/L
9 mg/dL
0.76 mg/dL
89 mg/dL

27 mmol/L
8 mg/dL
0.69 mg/dL
87 mg/dL

27 mmol/L
9 mg/dL
0.73 mg/dL
95 mg/dL

29 mmol/L
10 mg/dL
0.82 mg/dL
185 mg/dL

25 mmol/L
10 mg/dL
0.75 mg/dL
97 mg/dL

9.2 mg/dL
2.2 mg/dL
3.2 mg/dL

8.2 mg/dL
2.2 mg/dL
2.9 mg/dL

8.5 mg/dL
2.2 mg/dL
2.8 mg/dL

9.3 mg/dL
1.9 mg/dL

9.4 mg/dL







12.6 k/uL
14.8 gm/dL
3.9 mmol/L
27 mmol/L
20 mg/dL
0.61 mg/dL
93 mg/dL

9.7 k/uL
14.3 gm/dL
139 mmol/L

10.0 k/uL
14.1 gm/dL
139 mmol/L

11.6 k/uL
13.6 gm/dL
138 mmol/L

11.8 k/uL
13.1 gm/dL
140 mmol/L

3.6 mmol/L
104 mmol/L

3.7 mmol/L
101 mmol/L

3.9 mmol/L
101 mmol/L

3.6 mmol/L
103 mmol/L

27 mmol/L
18 mg/dL
0.64 mg/dL
99 mg/dL

29 mmol/L
15 mg/dL
0.76 mg/dL
88 mg/dL

29 mmol/L
11 mg/dL
0.78 mg/dL
87 mg/dL

28 mmol/L
10 mg/dL
0.81 mg/dL
87 mg/dL

85 mg/dL
7.2 gm/dL
0.12 mg/dL
11 units/L
40 units/L
3.0 gm/dL
0.2 mg/dL
150 units/L

8.1 gm/dL
19 units/L
67 units/L
3.4 gm/dL
0.4 mg/dL
203 units/L

Appendix B: Medications
At Home Medications:




400 mg/200

Oral- every 12
hours, 14 days
and IV



1 inhale

Nasal, 2 times
per day

Corticosteroid to
treat asthma,
allergies, and
postnasal drip

Metronidazole 500 mg/100


Oral every 8
hours, 14 days
and IV


40 mg

Oral 1 tablet
per day, 30


20 mg

Oral 2 tablets
per day, 30


Nutritional Implications
C. Diff-associated diarrhea,
should not be taken with
antacids containing magnesium
or aluminum or
supplements/food containing
calcium, iron, or zinc, may
increase effects of caffeine
Side effects include nausea or
vomiting, may affect patient

Contains sodium and should be

taken into consideration for
patients with high blood
pressure, avoid alcohol for at
least three days prior to taking
Proton pump
May inhibit folic acid, B12,
iron and beta-carotene
treatment of
absorption, avoid alcohol with
gastroesophageal this medication, may interact St.
reflux disease,
Johns wort, cayenne,
inhibits gastric
horseradish increase gastric
acid secretion
Limit sodium intake, steroids
increase bone loss increase
calcium and vitamin D intake

1. Clostridium Difficile (C. diff) a bacterium that is one of the most common causes of
infection of the colon.
2. Diastasis recti separation of rectus abdominis muscle into right and left halves.
3. Protein sparing solution (or peripheral protein sparing) nutrition therapy designed to
minimize nitrogen balance of a patient, but does not fully meet their nutrition needs.


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