The A.S.P.E.N. NUTRITION SUPPORT CORE CURRICULUM: A CASE-BASED APPROACH—THE ADULT PATIENT

EDITOR-IN-CHIEF

Michele M. Gottschlich, PhD, RD, LD, CNSDDirector, Nutrition Services

Shriners Hospitals for ChildrenCincinnati, OH

SECTION EDITORS

Mark H. DeLegge, MD, FACG, AGAFAssociate Professor of MedicineDirector, Section of Nutrition

Digestive Disease CenterMedical University of South Carolina

Charleston, SC

Todd Mattox, PharmD, BCNSPCoordinator, Nutrition Support Team

H. Lee Moffitt Cancer Center and Research InstituteTampa, FL

Charles Mueller, PhD, RD, CD, CNSDGeneral Clinical Research Center

Department of MedicineWeill/Cornell Medical College

New York, NY

Patricia Worthington, RN, MSN, CNSNNutrition Support Clinical Nurse Specialist

Thomas Jefferson University HospitalPhiladelphia, PA

MANAGING EDITOR

Peggi Guenter, PhD, RN, CNSNA.S.P.E.N. Program Director for Clinical Practice

Silver Spring, MD

AMERICAN SOCIETY FOR PARENTERAL AND ENTERAL NUTRITION

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is a scientific society whose members arehealth care professionals—physicians, dietitians, nurses, pharmacists, other allied health professionals, andresearchers—dedicated to assuring that every patient receives optimal nutrition care.

A.S.P.E.N.’s mission is to serve as a preeminent, interdisciplinary, nutrition society dedicated to patient-centeredclinical practice worldwide through advocacy, education, and research in specialized nutrition support.

NOTE: This publication is designed to provide accurate authoritative information in regard to the subject mattercovered. It is sold with the understanding that the publisher is not engaged in rendering medical or other profes-sional advice. Trademarked commercial product names are used only for education purposes and do not consti-tute endorsement by A.S.P.E.N.

This publication does not constitute medical or professional advice, and should not be taken as such. To the extentthe information published herein may be used to assist in the care of patients, this is the result of the sole profes-sional judgment of the attending health professional whose judgment is the primary component of quality med-ical care. The information presented herein is not a substitute for the exercise of such judgment by the healthprofessional.

All rights reserved. No part of this may be used or reproduced in any manner whatsoever without written permis-sion from A.S.P.E.N. For information write: American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.),8630 Fenton Street, Suite 412, Silver Spring, MD 20910-3805; (301) 587-6315, www.nutritioncare.org, email:aspen@nutr.org.

Copyright © 2007. American Society for Parenteral and Enteral Nutrition.

ISBN # 1-889622-08-7

Printed in the United States of America.

Contributors v

Reviewers xi

Foreword xvii

Preface xix

Acknowledgments xxiii

PART I Basics of Nutrition and Metabolism

1. Nutrient Intake, Digestion, Absorption, and Excretion 3Tina Colaizzo-Anas, PhD, RD, CDN

2. Energy 19Jennifer A. Wooley, MS, RD, CNSDDavid Frankenfield, MS, RD, CNSD

3. Carbohydrates 33Pei-Ra Ling, MDKaren C. McCowen, MD

4. Lipids 48Mary E. Hise, PhD, RD, CNSDJohn C. Brown, PhD

5. Protein 71Lorraine S. Young, RD, MS, CNSD, LDNLaurel R. Kearns, MS, RD, CNSD, LDNSandra L. Schoepfel, MS, RD, CNSD, LDN

6. Fiber 88Donna Zimmaro Bliss, PhD, RN, FAANHans-Joachim G. Jung, PhD

7. Fluid, Electrolytes, and Acid–Base Disorders 104Ginger Langley, PharmD, BCNSP, BCPS

8. Vitamins and Trace Elements 129Susan F. Clark, RD, PhD

PART II Clinical Foundations of Nutrition Support

9. Nutrition Screening and Assessment 163Mary Krystofiak Russell, MS, RD, LDN,

CNSDCharles Mueller, PhD, RD, CD, CNSD

10. Overview of Enteral Nutrition 187Mary Marian, MS, RDCarol McGinnis, MS, RN, CNSN

11. Enteral Formulations 209Jennifer Lefton, MS, RD, CNSDDema Halasa Esper, MS, RD, CNSDMarty Kochevar, MS, RPh, BCNSP

12. Enteral Access Devices 233Robin R. Bankhead, MS, CRNP, CNSNJohn C. Fang, MD

13. Complications of Enteral Nutrition 246 Ainsley M. Malone, MS, RD, LD, CNSDDavid S. Seres, MD, CNSPLinda Lord, NP, MS, CNSN

14. Overview of Parenteral Nutrition 264Jay M. Mirtallo, MS, RPh, BCNSP, FASHP

15. Parenteral Nutrition Formulations 277Jacqueline R. Barber, PharmD, BCNSP,

FASHPCarol J. Rollins, MS, RD, CNSD, PharmD,

BCNSPGordon S. Sacks, PharmD, BCNSP, FCCP

16. Parenteral Access Devices 300Elizabeth A. Krzywda, ANP, MSNDeborah A. Andris, ANP, MSNCharles E. Edmiston, PhDJames R. Wallace, MD, PhD

17. Complications of Parenteral Nutrition 323Vanessa J. Kumpf, PharmD, BCNSPJane Gervasio, PharmD, BCNSP

18. Drug–Nutrient Interactions 340Carol J. Rollins, MS, RD, CNSD,

PharmD, BCNSP

19. Alternative Medicine: Dietary Supplements 360Cathy L. Bartels, PharmD, FAAIMSarah J. Miller, PharmD, BCNSP

PART III Nutrition Support of Specific States

20. Pregnancy and Lactation 383Cathy Cimbalik, RN, RD, CNSDJames D. Paauw, MD, PhDAlan T. Davis, PhD

iii

Contents

21. Wound Healing 405Joyce K. Stechmiller, ARNP, PhDLinda Cowan, MSN, ARNP, CWSPaula Johns, RN, MSN, CNSN

22. Neurological Impairment 424Aaron M. Cook, PharmDJimmi Hatton, PharmD

23. Sepsis and Infection 440Robert G. Martindale, MD, PhDRebecca Sawai, MDMalissa Warren, RD

24. Trauma, Surgery, and Burns 455Gail A. Cresci, MS, RD, LD, CNSDMichele M. Gottschlich, PhD, RD, LD,

CNSDTheresa Mayes, RD, LDCharles Mueller, PhD, RD, CD, CNSD

25. Chylothorax and Chylous Ascites 477David A. Spain, MD, FACSStephen A. McClave, MD

26. Pulmonary and Cardiac Failure 487Denise Baird Schwartz, MS, RD, FADA,

CNSDRose Ann DiMaria, PhD, RN, CNSN

27. Gastrointestinal Disease 508Carol Rees Parrish, MS, RDJoe Krenitsky, MS, RDKate Willcutts, MS, RD, CNSDAmy E. Radigan, RD, CNSD

28. Liver Disease 540Philip C. Delich, MDJohn K. Siepler, PharmD, BCNSP, FCCPPatricia Parker, PharmD, BCPS

29. Pancreatitis 558Amy Tiu, MDStephen A. McClave, MD

30. Renal Disease 575Robert Wolk, PharmDEileen Moore, RD, LD, CNSDCharles Foulks, MD

31. Solid Organ Transplantation 599Jeanette M. Hasse, PhD, RD, LD, FADA,

CNSDLaura E. Matarese, MS, RD, LDN, FADA,

CNSD

32. Human Immunodeficiency Virus (HIV) Infection 619 Peter J. Wasserman, RD, MASorana Segal-Maurer, MD

33. Cancer 649Susan Roberts, MS, RD, LD, CNSDTodd Mattox, PharmD, BCNSP

34. Diabetes Mellitus 676Marie E. McDonnell, MDCaroline M. Apovian, MD

35. Obesity 695Denise Rollinson, MD, MS, RDScott A. Shikora, MDEdward Saltzman, MD

PART IV Management and Professional Issues36. Home Care 725

Mark H. DeLegge, MD, FACG, AGAFCarol Ireton-Jones, PhD, RD, LD, CNSD

37. Ethics 740Maria R. Andrews, MS, RD, FADA,

CNSD, CHECynthia M. A. Geppert, MD, PhD, FAPM

38. Quality Improvement 761 Janet Skates, MS, RD, LDN, CNSD, FADALillian Harvey-Banchik, MD, FACS,

CNSP

39. Evidence-Based Practice 783Kelly A. Tappenden, PhD, RDBree Zimmerman, BS

Index 791

iv C O N T E N T S

Maria R. Andrews, MS, RD, FADA, CNSD, CHEChief, Nutrition Support & Food ServiceNew Mexico VA Healthcare SystemAlbuquerque, NM

Deborah A. Andris, ANP, MSNAdult Nurse PractitionerMedical College of WisconsinMilwaukee, WI

Carolyn M. Apovian, MDDirector, Nutrition & Weight Management CenterBoston Medical Center Associate Professor of Medicine Boston University School of MedicineBoston, MA

Robin R. Bankhead, MS, CRNP, CNSNCoordinator, Nutrition Support ServiceTemple University HospitalDepartment of SurgeryPhiladelphia, PA

Jacqueline R. Barber, PharmD, BCNSP, FASHPPharmacy Clinical Specialist and Clinical ProfessorMethodist Hospital Pharmacy-Park Nicollet Health

Services St. Louis, MNCollege of Pharmacy, University of MinnesotaMinneapolis, MN

Cathy L. Bartels, PharmD, FAAIMAssociate ProfessorCreighton University School of PharmacyOmaha, NE

Donna Zimmaro Bliss, PhD, RN, FAANProfessor in Long-Term Care of EldersUniversity of MinnesotaSchool of NursingMinneapolis, MN

John C. Brown, PhDProfessor, Department of Molecular BiosciencesUniversity of KansasLawrence, Kansas

Cathy Cimbalik, RN, RD, CNSDClinical DietitianSpectrum Health-Butterworth100 Michigan Ave.Grand Rapids, MI

Susan F. Clark, RD, PhDAssociate ProfessorDirector, Didactic Program in DieteticsDepartment of Human Nutrition, Foods & ExerciseVirginia TechBlacksburg, VA

Tina Colaizzo-Anas, PhD, RD, CDNAssistant Professor Buffalo State—SUNYDietetics and NutritionBuffalo, NY

Aaron M. Cook, PharmDClinical Pharmacy Specialist—Neurosurgery/

Critical CareUniversity of Kentucky Chandler Medical CenterAdjunct Assistant ProfessorUniversity of Kentucky College of PharmacyLexington, KY

Linda Cowan, MSN, ARNP, CWSCEO Wound Healing Services, Inc.University of Florida College of NursingGainesville, FL

Gail A. Cresci, MS, RD, LD, CNSDAssistant Clinical Professor of SurgeryMedical College of GeorgiaDepartment of SurgeryAugusta, GA

v

Contributors

Alan T. Davis, PhDAssociate ProfessorMichigan State UniversityDepartment of SurgeryEast Lansing, MI

Mark H. DeLegge, MD, FACG, AGAFProfessor of MedicineMedical University of South CarolinaCharleston, SC

Philip C. Delich, MDRockwood Clinic GastroenterologySpokane, Washington

Rose Ann DiMaria, PhD, RN, CNSNAssociate ProfessorWest Virginia University School of NursingCharleston, WV

Charles E. Edmiston, PhDAssociate Professor of SurgeryMedical College of WisconsinMilwaukee, WI

Dema Halasa Esper, MS, RD, CNSDDietitian SpecialistUniversity of Pittsburgh Medical Center,

PresbyterianPittsburgh, PA

John C. Fang, MDAssociate Professor of Medicine, Interim

Division ChiefUniversity of UtahDivision of Gastroenterology Salt Lake City, UT

Charles Foulks, MD Professor of MedicineTexas A&M UniversityDirector, Division of Nephrology and HypertensionScott & White ClinicTemple, TX

David Frankenfield, MS, RD, CNSDChief Clinical DietitianMilton S. Hershey Medical CenterHershey, PA

Cynthia M. A. Geppert, MD, PhD, FAPMChief Liaison Consultant PsychiatristNew Mexico VA Healthcare SystemAlbuquerque, NM

Jane Gervasio, PharmD, BCNSPDirector of Clinical Research and ScholarshipAssistant Professor of Pharmacy PracticeButler University College of Pharmacy and

Health ScienceNutrition Support Clinical PharmacistClarian Health Partners Indianapolis, IN

Michele M. Gottschlich, PhD, RD, LD, CNSDDirector, Nutrition ServicesShriners Hospitals for ChildrenCincinnati, OH

Lillian Harvey-Banchik, MD, FACS, CNSPDepartment of SurgeryNorth Shore University HospitalManhasset, NY

Jeanette M. Hasse, PhD, RD, LD, FADA, CNSDTransplant Nutrition ManagerBaylor University Transplant InstituteDallas, TX

Jimmi Hatton, PharmDAssociate Professor, Pharmacy and NeurosurgeryUniversity of Kentucky College of PharmacyPharmacy Practice and ScienceLexington, KY

Mary E. Hise, PhD, RD, CNSDAssistant ProfessorDepartment of Dietetics & NutritionUniversity of Kansas Medical CenterKansas City, KS

Carol Ireton-Jones, PhD, RD, LD, CNSDNutrition Therapy SpecialistCarrollton, TX

Paula Johns, RN, MSN, CNSNNutritional Support Nurse ClinicianShands Hospital at the University of FloridaGainesville, FL

vi C O N T R I B U T O R S

Hans-Joachim G. Jung, PhDResearch Dairy Scientist and Adjunct ProfessorUSDA-Agricultural Research Service and University

of MinnesotaSt. Paul, MN

Laurel R. Kearns, MS, RD, CNSD, LDN Nutrition Support DietitianBoston Medical CenterBoston, MA

Marty Kochevar, MS, RPh, BCNSPNutrition Support PharmacistAmelia, OH

Joe Krenitsky, MS, RDNutrition Support SpecialistUniversity of Virginia Health SystemCharlottesville, VA

Elizabeth A. Krzywda, ANP, MSNAdult Nurse PractitionerMedical College of WisconsinMilwaukee, WI

Vanessa J. Kumpf, PharmD, BCNSPVanderbilt University Center for Human NutritionNashville, TN

Ginger Langley, PharmD, BCNSP, BCPSClinical Pharmacy SpecialistUniversity of Texas MD Anderson Cancer CenterHouston, TX

Jennifer Lefton, MS, RD, CNSD Clinical DietitianJackson Health SystemMiami, FL

Pei-Ra Ling, MDAssistant Professor of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBoston, MA

Linda Lord, NP, MS, CNSNNurse PractitionerUniversity of Rochester Medical Center Rochester, NY

Ainsley M. Malone, MS, RD, LD, CNSDNutrition Support Team Mt. Carmel West HospitalColumbus, OH

Mary Marian, MS, RDClinical Nutrition Research SpecialistUniversity of Arizona College of MedicineTucson, AZ

Robert G. Martindale, MD, PhDProfessor of Surgery, Medical Director for Hospital

Nutrition Services Oregon Health and Science UniversityPortland, OR

Laura E. Matarese, MS, RD, LDN, FADA, CNSDDirector of Nutrition, Intestinal Rehabilitation and

Transplant CenterThomas E. Starzl Transplantation InstituteUniversity of Pittsburgh Medical Center Pittsburgh, PA

Todd Mattox, PharmD, BCNSPCoordinator, Nutrition Support TeamH. Lee Moffitt Cancer Center and Research InstituteTampa, FL

Theresa Mayes, RD, LDClinical DietitianShriners Hospitals for ChildrenCincinnati, OH

Stephen A. McClave, MDProfessor of MedicineDivision of Gastroenterology/HepatologyUniversity of Louisville School of MedicineLouisville, KY

Karen C. McCowen, MDAssistant Professor of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBoston, MA

Marie E. McDonnell, MDDirector of Inpatient Diabetes ProgramSection of Endocrinology, Diabetes, and NutritionBoston Medical CenterBoston, MA

C O N T R I B U T O R S vii

Carol McGinnis, MS, RN, CNSNClinical Nurse SpecialistSioux Valley Hospital University of South Dakota Medical CenterSioux Falls, SD

Sarah J. Miller, PharmD, BCNSPProfessor, University of Montana Skaggs School

of PharmacyMissoula, MT

Jay M. Mirtallo, MS, RPh, BCNSP, FASHPSpecialty Practice Phamacist, Nutrition

Support/SurgeryThe Ohio State University Medical CenterDepartment of Pharmacy Columbus, OH

Eileen Moore, RD, LD, CNSDRenal DietitianParma Davita DialysisParma, OH

Charles Mueller, PhD, RD, CD, CNSDGeneral Clinical Research CenterDepartment of MedicineWeill/Cornell Medical CollegeNew York, NY

James D. Paauw, MD, PhDDirector, Nutrition SupportSpectrum Health/Michigan State UniversityGrand Rapids, MI

Patricia Parker, PharmD, BCPSClinical Supervisor/Critical Care Pharmacist UC Davis Medical CenterAssistant Clinical ProfessorUCSF School of PharmacySacramento, CA

Carol Rees Parrish, MS, RDNutrition Support SpecialistUniversity of Virginia Health SystemDigestive Health Center of ExcellenceCharlottesville, VA

Amy E. Radigan, RD, CNSD Nutrition Support SpecialistUniversity of Virginia Health SystemCharlottesville, VA

Susan Roberts, MS, RD, LD, CNSDAssistant Director of Clinical Nutrition Manager Nutrition Support Team CoordinatorBaylor University Medical CenterDallas, TX

Carol J. Rollins, MS, RD, CNSD, PharmD, BCNSPCoordinator, Nutrition Support TeamClinical Associate ProfessorUniversity Medical Center and The University of Arizona College of PharmacyTucson, AZ

Denise Rollinson, MD, MS, RDAssistant Professor of MedicineTufts University School of MedicineTufts—New England Medical CenterBoston, MA

Mary Krystofiak Russell, MS, RD, LDN, CNSDAssistant Director, Nutrition Servicesand Adult Lung Transplant DietitianUniversity of Chicago HospitalsChicago, IL

Gordon S. Sacks, PharmD, BCNSP, FCCPClinical Associate ProfessorUniversity of Wisconsin—MadisonMadison, WI

Edward Saltzman, MDJean Mayer USDA Human Nutrition Research Center

on Aging Tufts UniversityBoston, MA

Rebecca Sawai, MD Surgical ResidentOregon Health and Science UniversityPortland, OR

Sandra L. Schoepfel, MS, RD, CNSD, LDN Nutrition Support DietitianBoston Medical CenterBoston, MA

Denise Baird Schwartz, MS, RD, FADA, CNSDNutrition Support CoordinatorProvidence Health Care SystemSan Fernando Valley Service AreaBurbank, CA

viii C O N T R I B U T O R S

Sorana Segal-Maurer, MDAttending PhysicianInfectious Disease Division, Department of MedicineNew York Hospital, QueensFlushing, NY

David S. Seres, MD, CNSPAssistant Professor, Albert Einstein College

of MedicineChief, Division of Perioperative Medicine

and Nutrition SupportBeth Israel Medical CenterNew York, NY

Janet Skates, MS, RD, LDN, CNSD, FADANutrition ConsultantNutrition Consulting ServicesKingsport, TN

Scott A. Shikora, MDProfessor of MedicineTufts University School of MedicineTufts—New England Medical CenterBoston, MA

John K. Siepler, PharmD, BCNSP, FCCPResearch SpecialistNutrishare, Inc.Clinical Professor, UCSF School of PharmacyElk Grove, CA

David A. Spain, MD, FACSChief of Trauma/Critical CareStanford UniversityStanford, CA

Joyce K. Stechmiller, ARNP, PhDAssociate ProfessorUniversity of Florida College of NursingGainesville, FL

Kelly A. Tappenden, PhD, RDAssociate Professor of Nutrition and Gastrointestinal

PhysiologyUniversity of Illinois at Urbana–ChampaignUrbana, IL

Amy Tiu, MD Clinical Instructor, GI FellowUniversity of Louisville School of MedicineDivision of Gastroenterology/HepatologyLouisville, KY

James R. Wallace, MD, PhDAssociate ProfessorMedical College of WisconsinMilwaukee, WI

Malissa Warren, RDDepartment of SurgeryOregon Health and Science UniversityPortland, OR

Peter J. Wasserman, RD, MAMetabolic Support CoordinatorInfectious Disease Division, Department of MedicineNew York Hospital, QueensFlushing, NY

Kate Willcutts, MS, RD, CNSDNutrition Support Specialist/Assistant ProfessorUniversity of Virginia Health System/School

of NursingCharlottesville, VA

Robert Wolk, PharmDManager, Clinical and EducationDepartment of PharmacyTucson Medical CenterTucson, AZ

Jennifer A. Wooley, MS, RD, CNSDNutrition Support DietitianSt. Joseph Mercy HospitalAnn Arbor, MI

Lorraine S. Young, RD, MS, CNSD, LDN Home Nutrition Support ManagerBoston Medical CenterBoston, MA

Bree Zimmerman, BSUniversity of Illinois, UrbanaUrbana, IL

C O N T R I B U T O R S ix

Jorge Albina, MDProfessor of SurgeryBrown UniversityProvidence, RI

Kunihiko Aoyagi, MD, PhDAssociate ProfessorThird Department of Internal MedicineFaculty of MedicineFukuoka UniversityFukuoka, Japan

Scott E. Apelgren, MD, BCPS, BCOP, BCNSPDecentral Pharmacist-Hemotology/OncologyMayo Clinic-Rochester Methodist HospitalRochester, MN

David A. August, MDProfessor of SurgeryChief, Division of Surgical OncologyUMDNJ/Robert Wood Johnson Medical School and

The Cancer Instititute of New JerseyNew Brunswick, NJ

Laurie Beebe, MS, RD, LD, CNSDHome Health DietitianBJC Home CareO’Fallon, IL

Mary Ellen Beindorff, RD, LDTransplant Nutrition SpecialistBarnes-Jewish HospitalSt. Louis, MO

Donna Zimmaro Bliss, PhD, RN, FAANProfessor in Long-Term Care of EldersUniversity of MinnesotaSchool of NursingMinneapolis, MN

Viviane Chaer BorgesDietitian and Doctoral Candidate UNIFESPSpecialist in Enteral and Parenteral Nutrition Brazilian Pareneral and Enteral SocietyGANEP Crupo de Nutricao HumanaSão PauloSão Paulo, Brazil

Joseph Boullata, PharmD, BCNSPAdjunct Professor of Pharmacology & TherapeuticsUniversity of PennsylvaniaPhiladelphia, PA

Richard Branson, MS, RRTAssociate Professor of SurgeryUniversity of CincinnatiCincinnati, OH

Rex O. Brown, PharmDProfessor of PharmacyUniversity of Tennessee Health Science CenterMemphis, TN

Imad F. Btaiche, PharmD, BCNSPClinical Associate Professor of Pharmacy and Clinical PharmacistDepartment of Clinical Services, University

of Michigan College of Pharmacy and Departmentof Pharmacy Services, University of Michigan Hospitals and Health Centers

Ann Arbor, MI

Phila Callahan, RN, CNSNHome Nutrition Support NurseChristiana Care Infusion ServiceNewark, DE

Sheila M. Campbell, PhD, RDPartner, HealthCare CreativeHealthCare CreativeColumbus, OH

xi

Reviewers

Lingtak-Neander Chan, PharmD, BCNSPAssociate ProfessorSchool of PharmacyUniversity of WashingtonSeattle, WA

David Charney, MD, FACP, FASNNephrologist, Group Health PermanenteSeattle, WA

Ayaz Chaudhary, MD, FACP, FACGAssistant Professor of MedicineSection of Gastroenterology/HepatologyMedical Director, Special Procedures/

Endoscopy UnitMedical College of GeorgiaAugusta, GA

Krista M. Clark, RD, LD, CNSDClinical Nutrition ManagerSt. Elizabeth Medical CenterEdgewood, KY

Stephen Clarke, MS, RD, CNSD, LDNClinical Dietitian SpecialistTemple University HospitalPhiladelphia, PA

Coryn Commare, RD, CNSDGreenfield, WI

Luc Cynober, PharmD, PhDProfessor of Biological NutritionClinical Chemistry LaboratoryHotel-Dieu HospitalLaboratory of Biological NutritionParis 5 UniversityParis, FRANCE

Lora N. Day, MA, RD, CNSDAdvanced Practice Clinical DietitianNutrition Support TeamParkland Health & Hospital SystemDallas, TX

Michele A. DeBiasse, MS, RD, LD, CNSDClinical Nutrition ManagerCaritas-St. Elizabeth’s Medical CenterBoston, MA

Robert DeChicco, MS, RD, LD, CNSDManager, Nutrition Support DieteticsCleveland ClinicCleveland, OH

Sharon Del Bono, RD, CNSD, LDNClinical Dietitian SpecialistTemple University HospitalPhiladelphia, PA

Himanshu P. Desai, MDTrinity Health Systems and Riverside Medical

of OhioSteubenville, OH

Roland N. Dickerson, PharmD, BCNSP, FACN, FCCPProfessor of PharmacyUniversity of Tennessee Health Science CenterMemphis, TN

Marianne Duda, MS, RD, LD/N, CNSDNational Nutrition Program ManagerCorporate Nutrition Team LeaderOption Care, Inc.St. Petersburg, FL

Carrie P. Earthman, PhD, RD, LDAssistant Professor and Director and Coordinated

Programs in DieteticsUniversity of Minnesota, Department of Food

Science and NutritionSt. Paul, MN

Eric H. Frankel, MSE, PharmD, BCNSPNutrition Support Service Coordinator/Director

of ResidencyCovenant Health SystemLubbock, TX

Amy Freeman, RD, LD, CNSDChief Clinical DietitianGateway Medical CenterClarksville, TN

M. Patricia Fuhrman, MS, RD, LD, FADA, CNSDArea Clinical Nutrition Marketing Manager-CentralAdvanced Nutrition ServicesCoram HealthcareSt. Louis, MO

Debra K. Gardner, BS, PharmDSpecialty Practice Pharmacist, Women and InfantsOhio State University Medical CenterDepartment of PharmacyAssistant Clinical ProfessorOhio State University College of PharmacyColumbus, OH

xii R E V I E W E R S

Marshall J. Glesby, MD, PhDAssociate Professor of Medicine and Public HealthWeill Medical College of Cornell UniversityNew York, NY

Suzanne W. Gore, MS, RD, LDNutrition Support/Renal DietitianVeterans Administration HospitalLexington, KY

Linda Griffith, PhD, RD, LD, CNSDClinical Assistant ProfessorDepartment of Dietetics & NutritionUniversity of Kansas Medical CenterKansas City, KS

Peggi Guenter, PhD, RN, CNSNProgram Director for Clinical PracticeAmerican Society for Parenteral and

Enteral NutritionSilver Spring, MD

Kathy Hammond, MS, RN, RD, LD, CNSDCoordinator, Continuing Education/Clinical

Nutrition SpecialistChartwell Diversified Services, Inc.Adjunct Assistant ProfessorDepartment of Foods and NutritionUniversity of GeorgiaSharpsburg, GA

Therese L. Han-Markey, MS, RD, CNSDBionutrition ManagerUniversity of Michigan Medical Center General

Clinical Research CenterAnn Arbor, MI

Jane Harper, MS, RNAdjunct Assistant Professor of Clinical NursingCollege of NursingUniversity of CincinnatiCincinnati, OH

Beverly J. Holcombe, PharmD, BCNSP, FASHPSenior Clinical SpecialistDepartment of PharmacyUNC HealthcareChapel Hill, NC

Wanda H. Howell, PhD, RDProfessor, Department of Nutritional SciencesUniversity of ArizonaTucson, AZ

Nancy Lee Hsieh, MS, MPH, RD, CNSDClinical Dietitian, Critical CareStanford University Medical CenterStanford, CA 94305

Carol Ireton-Jones, PhD, RD, LD, CNSD, FACNNutrition Therapy SpecialistGood Nutrition for Good LivingCarrollton, TX

Aminah Jatoi, MDAssociate ProfessorMayo ClinicRochester, MN

Khursheed N. Jeejeebhoy, MBBS, PhD, FRCPCEmeritus Professor of MedicineUniversity of TorontoSt. Michael’s HospitalToronto, OntarioCanada

Deborah R. Johnson, MS, RNClinical Nurse SpecialistMeriter HospitalMadison, WI

Jeanette Newton Keith, MDAssistant Professor of MedicineUniversity of ChicagoChicago, IL

Claudia Kelley, MPH, MS, RD, CDE, CNSDAssistant Professor Clinical NutritionSouthern California University of Health ScienceWhittier, CA

Elizabeth Kile, RD, CNSD, LDNNutrition Support SpecialistConsultantPhiladelphia, PA

Jodi Kingley, MS, RD, CNSDClinical Nutrition ManagerColumbus HospitalNewark, NJ

Carol Kohn-Keeth, DNSc, RNAssociate ProfessorLewis University College of NursingRomeoville, IL

R E V I E W E R S xiii

Debra S. Kovacevich, RN, MPHNurse Manager, Clinical Assistant Professor

of PharmacyHomeMed and College of PharmacyUniversity of MichiganAnn Arbor, MI

Kenneth A. Kudsk, MD, FACSProfessor of SurgeryUniversity of Wisconsin—MadisonDepartment of SurgeryMadison, WI

Gary M Levine, MDProfessor of Medicine, Dartmouth Medical SchoolHead, Clinical Nutrition, Section

of GastroenterologyDartmouth Hitchcock Medical CenterLebanon, NH

Cynthia L. Lieu, PharmD, BCNSPAssociate Professor of Clinical PharmacyUniversity of Southern CaliforniaSchool of PharmacyLos Angeles, CA

Joanna Lipp, MS, RD, CNSD, CDEClinical Nutrition SpecialistStrong Memorial HospitalUniversity of RochesterRochester, NY

Beth Lyman, MSN, RNNutrition Support Nurse CoordinatorChildren’s Mercy HospitalKansas City, MO

Georganne Mackulin, MA, RD, CDEManager Clinical Jefferson Regional Medical CenterPittsburgh, PA

Julie O’Sullivan Maillet, PhD, RD, FADAAssociate Dean for Academic Affairs & ResearchUniversity of Medicine and Dentistry of New JerseySchool of Health-Related ProfessionsNewark, NJ

Carol McGinnis, MS, RN, CNSNClinical Nurse SpecialistSioux Valley Hospital University of South Dakota Medical CenterSioux Falls, SD

Remy Meier, MDAssociate ProfessorUniversity Hospital, Gastroenterology UnitLiestal, Switzerland

Norma A. Metheny, RD, PhD, FAANProfessor and Dorothy A. Votsmier Endowed Chair

in NursingSaint Louis University School of NursingSt. Louis, MO

Laurie Metzger, MS, RD, CNSDClinical NutritionistKindred HospitalScottsdale, AZ

Joseph A. Molnar, MD, PhDAssociate Professor of Plastic and Reconstructive

SurgeryWake Forest University School of MedicineWinston–Salem, NC

Dawna Torres Mughal, PhD, RD, LDN, FADADirector, Dietetics ProgramCollege of Sciences, Engineering, and Health SciencesGannon UniversityErie, PA

Gerard E. Mullin, MD, CNSPAssistant Professor of MedicineDivision of GastroenterologyThe Johns Hopkins University School of MedicineBaltimore, MD

Lynne M. Murphy, RN, MSN, CNSNNutrition Support NurseAnnandale, VA

Laure Newton, MA, RDInstructor, University of Alabama at BirminghamDepartment of Nutrition SciencesBirmingham, AL

Liesje L. Nieman, RD, CNSD, LDNNutrition Support/Clinical DietitianThe Children’s Hospital of PhiladelphiaPhiladelphia, PA

C. Scott O’Banion, PharmD, BCNSPNutrition Support Pharmacist University Medical CenterLubbock, TX

xiv R E V I E W E R S

Stephen J. O’Keefe, MDProfessor of Medicine University of PittsburghPittsburgh, PA

Susan Roberts, MS, RD, LD, CNSDClinical Nutrition Manager and Nutrition Support

Team CoordinatorNutrition ServicesBaylor University Medical CenterDallas, TX

Joanne Z. Rogers, RN, MSN, CNSNClinical Nurse SpecialistGeisinger Medical CenterDanville, PA

John L. Rombeau, MDProfessor of SurgeryUniversity of Pennsylvania School of MedicineHospital of the University of PennsylvaniaPhiladelphia, PA

Marcia Ryder, PhD, MS, RNResearch and Consulting: Medical Biofilms,

Healthcare-Acquired InfectionsVascular AccessSan Mateo, CA

Abigail E. Schubert, RD, CNSD, LDNClinical DietitianPenn State Milton S. Hershey Medical CenterHershey, PA

Denise Baird Schwartz, MS, RD, FADA, CNSDNutrition Support CoordinatorProvidence Health Care SystemSan Fernando Valley Service AreaBurbank, CA

Jane Jeffrie Seley, NP, CDEDiabetes Nurse PractitionerNew York Presbyterian/ Weill CornellNew York, NY

Annalynn Skipper, PhD, RD, FADAAuthor and ConsultantOak Park, IL

Rex Speerhas, RPh, CDE, BCNSPNutrition Support Clinical SpecialistDepartment of PharmacyCleveland Clinic FoundationCleveland, OH

Krishnan Sriram, MDChairman, Division of Surgical Critical CareChief, Section of Surgical NutritionJohn H. Stroger Jr. Hospital of Cook CountyChicago, IL

Ezra Steiger, MD, FACS, CNSPProfessor of Surgery, Head Intestinal RehabilitationCo-Director, Nutrition Support TeamCleveland Clinic FoundationCleveland, OH

Marsha R. Stieber, MSA, RD, CNSDStudent Service Coordinator/Dietetic Internship

DirectorArizona Department of Health ServicesOffice of Chronic Disease Prevention and

Nutrition ServicesPhoenix, AZ

Gilberto Fabian Hurtado Torres, MDAssociate Professor of Internal Medicine and

Clinical NutritionChief of Clinical Nutrition and Metabolic Support

ServiceFaculty of Medicine, University Autonomous

of San Luis Potosí and Central Hospital Dr. Ignacio Morones Prieto San Luis Potosí, Mexico

Vince W. Vanek, MD, FACS, CNSPAssociate Director of Surgical EducationSt. Elizabeth Health CenterYoungstown, OHProfessor of SurgeryNortheastern Ohio University School of MedicineRootstown, OH

Lee Varella, RN, MSN, CNS, ANP-CAssociate Director of Surgical Nutrition ServiceUniversity Hospital-State University of New YorkUpstate Medical UniversitySyracuse, NY

R E V I E W E R S xv

Jennifer A. Wooley, MS, RD, CNSDNutrition Support DietitianSt. Joseph Mercy HospitalAnn Arbor, MI

Cathy L. Worrall, BSN, RN, PharmD, BCPS, BCNSP,FAPhA

Clinical Pharmacy Specialist—Surgical Critical Care,Trauma and Nutrition Support

Clinical Associate ProfessorMedical University of South Carolina Medical Center

and South Carolina College of Phamacy—Charleston Campus

Charleston, SC

Yi-Hao Yu, MD, PhDAssistant Professor of MedicineDirector, Adult Nutrition/TPN ServiceNew York Presbyterian HospitalColumbia University College of Physicians and Sur-

geonsNew York, NY

xvi R E V I E W E R S

A.S.P.E.N. is the pre-eminent, interdisciplinary nutri-tion society dedicated to patient-centered, clinicalpractice worldwide through advocacy, education, andresearch in specialized nutrition support. The key-word in this mission statement is “interdisciplinary.”What makes A.S.P.E.N. unique in the scientific andhealthcare community is its interdisciplinary focus.Traditionally, the term “interdisciplinary” has beeninterpreted to mean multiple disciplines workingtogether to bring a comprehensive team perspective tonutrition support and patient care. But A.S.P.E.N. isinterdisciplinary in many other ways—nutrition sup-port clinicians practicing in multiple settings (acutecare, chronic care, long-term care, home care); provid-ing care to diverse patient populations (adults, pedi-atrics, geriatrics); and providing an environment forbasic, translational, and outcomes research in nutri-tion and metabolism.

The A.S.P.E.N. Nutrition Support Core Curriculum: ACase-Based Approach—The Adult Patient provides thetools necessary for clinicians to translate knowledgeinto practice. It focuses on the interdisciplinary natureof nutrition support practice replacing previous corecurricula that were discipline specific. This core cur-riculum recognizes a common set of core competen-cies to which all healthcare professionals working innutrition support should ascribe. Furthermore, thistext is a must-have for all professionals planning toobtain certification in nutrition support in prepara-tion for the first interdisciplinary examination.

This core curriculum is the first of three volumesand focuses strictly on the adult. Soon to follow willbe core curricula specific to pediatrics and geriatrics.The content of the adult core curriculum has been sig-nificantly expanded with many new authors and it in-cludes new chapters focusing on carbohydrate, lipid,protein, fiber, as well as complementary and alterna-

tive medicine. The clinical foundations of nutritionsupport are again highlighted with comprehensivechapters focusing on nutrition screening and assess-ment, and enteral and parenteral nutrition. The heartof the core is the extensive section on nutrition sup-port of specific disease states and clinical conditions.Finally, important professional issues are addressed inchapters on home care, ethics, quality improvement,and evidence-based practice. The core is unique in itsability to develop the learner’s critical thinking andproblem-solving skills. Behavioral objectives arestated at the beginning of each chapter, followed by apre-test with explanations of the correct and incorrectanswers, didactic material, and case study illustrationswith thought-provoking questions and answers. Asearchable CD-rom is included to allow learners tomove efficiently through the curriculum.

A major strength of the core curriculum is reflectedin the expertise and extensive clinical experience ofits Editor-in-Chief. Michele Gottschlich, PhD, RD,LD, CNSD is a highly regarded and renowned expertin nutrition support and, once again, brings to thenutrition community a superb text combining qual-ity science with the best available clinical practiceinformation. Her team of section editors and out-standing contributors has succeeded in producingthe most comprehensive interdisciplinary, evidence-based approach to nutrition support practice.

Marion F. Winkler, MS, RD, CNSDPresident, The American Society for Parenteral andEnteral Nutrition

and

Senior Clinical Teaching Associate of SurgeryRhode Island Hospital and Brown Medical SchoolProvidence, Rhode Island

xvii

Foreword

VisionWe began this book with a vision. Our primary goalwas to produce a written resource containing corescience (why) and core practical (how to) of nutritionsupport principles in alignment with the contempo-rary format of problem-based learning, a commonpractice today in medical and allied health schools. Toengage the reader effectively in this type of activelearning, the content of the book was structured insuch a way that didactic background informationwould be provided as a starting point, from whichdecisions would be made. Obviously, the didacticmatter and case studies play distinctly different rolesin the process of learning, and the reader is expectedto benefit from synergy between the two.

The strategic plan for text development encompasseda number of secondary objectives as well. The Core Cur-riculum would be shaped by the American Society forParenteral and Enteral Nutrition’s (A.S.P.E.N.’s) S t a n-dards of Practice,1 – 7 Clinical Guidelines,8 Parenteral Nutri-tion Safe Practices,9 prior discipline-specific N u t r i t i o nSupport Core Curriculums,1 0 , 1 1 and the I n t e r d i s c i p l i n a r yStrategic Plan1 2 and would serve as a companionresource to the Nutrition Support Practice Manual.1 3 It wasour prospective intent to create a text that would be use-ful to those preparing for the specialization certific a t i o nexam in nutrition support. In addition, the Editors con-sidered the needs of the generalist and structured thebook so that the production of a valuable resource forthat population would be achieved as well. We alsowanted to provide organized supplemental material forparticipants of A.S.P.E.N.’s Interdisciplinary ReviewCourse in a manner that optimizes the concentratedlearning experience. A final objective was to create aninterdisciplinary document that meets the educationalrequirements of physicians, dietitians, nurses, and phar-macists alike while promoting collaboration across thedisciplines. It is our hope that our endeavor results inan effective learning experience, true reader satisfactionand, ultimately, improved patient care.

BackgroundA.S.P.E.N. has previously published two editions of adietetics core curriculum,10 three editions of a nursingcore curriculum,1 1 and pharmacy-selected cases for aself-study guide.1 4 These texts have been widely usedin the past as professional references, student text-books, and also as study guides for certification andboard examination. In alignment with A.S.P.E.N.’sinterdisciplinary model for organizational structureand educational programming and, also, in recogni-tion of the concept of the multidisciplinary team con-tinuum of care,1 2 the decision was made to produce anintegrated, unified core curriculum.

In 2001, publication of The Science and Practice ofNutrition Support: A Case-Based Core Curriculum15 rep-resented A.S.P.E.N.’s first interdisciplinary core cur-riculum. This book covered the entire age spectrumfrom neonates to geriatrics and was highly successfulaccording to sales data. To obtain feedback from thereaders following 3 years on the market, a survey wasdistributed to A.S.P.E.N. membership in 2004, and294 responses were received. The vast majority foundthe book to be helpful, and most liked the case studyformat and accompanying CD. More than 83% indi-cated that they would purchase a second edition ofthis book. Over 47% believed that select content areasshould be enhanced. Foremost among the requestedadditions were many suggestions and requests formore pediatric, neonatal, and geriatric material.

With all of these data in mind and with requestsfrom A.S.P.E.N. Pediatric and Geriatric Sections andindividual practitioners, the Board of Directorsapproved the proposal of a three-volume set of CoreCurriculum across the lifespan. This publication rep-resents the first volume, which strictly focuses on theadult patient. Separate Geriatric and Pediatric CoreCurriculums are in the development phase.

Besides concentrating on the adult, other extensivechanges from the original interdisciplinary core cur-r i c u l u m1 5 have been made. The A.S.P.E.N. N u t r i t i o n

xix

Preface

Support Core Curriculum: A Case-Based Approach—The Adult Patient has a new publisher, 5 new editors,6 new chapters, and 68 new authors.

Considerable forethought was given as to how toensure that both core nutrition support informationcommon to all disciplines as well as critical discipline-s p e c i fic content would be delivered. To achieve thisoutcome, we specifically based the content of thisbook according to the National Board of NutritionSupport certification examination blueprints for dieti-tians, nurses, and physicians. We focused the phar-macy content using the certification test outlinegenerated by the Board of Pharmaceutical Specialties.First, a systematic content analysis of the four outlinesfor the four discipline exams was performed. Com-mon areas, as well as knowledge and skills unique toeach discipline, were ascertained. From this compari-son, we developed a comprehensive content outline.Next, we grouped similar topics in the content outlinefor discussion in the same chapter. This exercise pro-vided an organizational framework for the book’scontents, and it also served to guide the invitedauthors in preparing subject matter for their chapters.In addition, the editors used the content outline as anindex when evaluating manuscripts to ensure that crit-ical content was addressed.

Design and Organization of the BookEach chapter in The A.S.P.E.N. Nutrition Support CoreCurriculum: A Case-Based Approach—The Adult Patientbegins with primarily evidence-based, didactic back-ground information that describes core science. Thismaterial is supported by practical case scenarios. Casestudies represent powerful teaching tools,1 6 , 1 7 and wefelt that there were three strong arguments for incorpo-rating such clinical reasoning exercises into this docu-ment. First, case methods teach the learner decis i o n -making and problem-solving skills while reinforcingthe theory and principles of science. Case studies fur-ther assist in the transfer of learning from a scientificbasis to a clinical basis utilizing application and prac-tice, and it helps the learner make the transition fromsimple to complex situations. Case methods alsoallow the reader to apply critical-thinking skills andtherapeutic reasoning.

Second, The A.S.P.E.N. Nutrition Support Core Cur-riculum: A Case-Based Approach—The Adult Patient i sintended for the adult learner who already possesses abasic knowledge of the principles of food and nutritionand the relation to wellness and disease processes.

Adult learners are highly motivated to build on coreknowledge to solve practical situations. Within thecase-method approach, simple-to-complex levels oflearning and behavior can be incorporated at a gradualself-learning pace. Because these adult learners areknowledgeable, they can self-direct their learning alongwith the many other responsibilities in their daily lives.

Third, a large segment of the nutrition supportboard exam is derived from case examples. This isoften difficult for some test-takers. Many people seemto be much more comfortable with memorizing. Thecase-method approach motivates test-takers by havingthem take a more active role in defining and solvingproblems using analytical skills, as compared to thetraditional read-and-memorize approach.

In addition to the didactic information and case stud-ies, there are a number of additional organizational fea-tures to assist the reader in rapid information retrievalwhile maximizing the learning experience. A mini Tableof Contents is a component of each of the 39 chapters,serving to quickly generate a sense of chapter contents.Learning objectives are included to help establish eachindividual chapter’s educational goals. The “Test YourKnowledge” questions and answers that precede thedidactic material serve as a pretest to help readers focuson what they need to learn regarding the subject matter.There is an extensive index, numerous interchapterreferrals, and, also, a CD version of this manual to facil-itate searches for specific information.

Eighty-six authors and 90 reviewers (22% physi-cians, 34% dietitians, 14% pharmacists, 14% nurses,and 16% PhDs) from 35 states and 7 countries char-acterize the interdisciplinary and global nature of thisbook. The thread of collaborative management ofnutrition support is evident throughout this publica-tion. The text is organized into four sections. Part I laysthe foundation by providing an overview of digestion,absorption, metabolism, and requirements for energyand nutrients. Energy, protein, carbohydrate, fib e r ,and fat needs are covered. Attention is also devoted tofluid, electrolyte, vitamin, mineral, and trace elementrequirements. The book transitions to principles ofnutrition support in Part II, whereby an overview ofenteral and parenteral feeding methods and pharma-cotherapeutic considerations are detailed. A logicalprogression is then made to nutrition support duringspecific disease states and conditions (Part III). Part IVstudies management and professional issues, in-cluding home care, ethics, quality improvement, and evidenced-based practice.

Finally, something must be said about the possibil-ity that alternative care plans may come to the reader’s

xx P R E F A C E

mind. Certainly, there often exist a number of diag-nostic or treatment options for any given patient sce-nario. However, it should be recognized that oursolutions have been based on scientific evidence, clin-ical standards, and clinical guidelines whenever pos-sible. We hope you find that we achieved our vision ofcreating a book that enhances your critical thinkingcapabilities relevant to nutrition support.

Michele M. GottschlichEditor-in-Chief

References1. A.S.P.E.N. Board of Directors. Standards for specialized

nutrition support: adult hospitalized patients. Nutr ClinPract. 2002;17:384–391.

2. A.S.P.E.N. Board of Directors. Standards for specializednutrition support: home care patients. Nutr Clin Pract.2005;20:579–590.

3. A.S.P.E.N. Board of Directors. Standards of practice:nutrition support pharmacist. Nutr Clin Pract. 1 9 9 9 ;14:275–281.

4. A.S.P.E.N. Board of Directors. Standards of practice fornutrition support dietitians. Nutr Clin Pract. 2 0 0 0 ;53:53–59.

5 . A.S.P.E.N. Board of Directors. Standards of practice:nutrition support nurse. Nutr Clin Pract. 2 0 0 1 ; 1 6 : 5 6 – 6 2 .

6. A.S.P.E.N. Board of Directors. Standards of practice:nutrition support physician. Nutr Clin Pract. 2 0 0 3 ;18:270–275.

7. A.S.P.E.N. Board of Directors. Standards for specializednutrition support for adult residents of long term facil-ities Nutr Clin Pract. 2006;21:96–104.

8. A.S.P.E.N. Board of Directors and The Clinical Guide-lines Task Force. Guidelines for the use of parenteraland enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr. 2002;26 (1 suppl):1SA-138SA.

9. Task Force for the Revision of Safe Practices for Par-enteral Nutrition. Safe practices for parenteral nutrition.J Parenter Enteral Nutr. 2004;28:S39–S70.

10. Gottschlich MM. Matarese LE, Shronts ER, eds. N u t r i t i o nSupport Dietetics Core Curriculum. 2nd ed. Silver Spring,MD: A.S.P.E.N.; 1993.

11. Hennessy KA, Orr ME, eds. Nutrition Support Nursing.3rd ed. Silver Spring, MD: A.S.P.E.N.; 1996.

12. A.S.P.E.N. Board of Directors. Itinerary for tomorrow.A.S.P.E.N.’s new strategic plan. Nutr Clin Pract. 1 9 9 5 ;10:243–247.

13. Merritt RJ, ed. The A.S.P.E.N. Nutrition Support PracticeManual. 2nd edition. Silver Spring, MD: A.S.P.E.N.;2005.

14. Christensen ML, McKinnon BT. Nutrition Support Phar-macy. Selected Cases for Self-Study. Silver Spring, MD:A.S.P.E.N.; 1995.

15. Gottschlich MM, ed. The Science and Practice of NutritionSupport: A Case-Based Core Curriculum. Dubuque, IA:A.S.P.E.N./ Kendall Hunt Publishing Co.; 2001.

16. Coccia CT, Ausman JI. Is a case report an anecdote: indefense of personal observations in medicine. Surg Neurol. 1987;28:111–113.

17. Gottschlich MM. Writing basics: elements of the casestudy. J Am Diet Assoc. 2000;100:1293–1295.

P R E F A C E xxi

I express my sincere gratitude to the many peoplewhose help and encouragement contributed to thispublication. First and foremost, I am truly indebted tomy stellar Associate Editors: Charlie Mueller, whowith his keen sense of vision and evidence-based crit-ical thinking aptitudes notwithstanding his back-ground in dietetics, education, research, and nutritionsupport certification did a remarkable job as an author(Chapters 9 and 24) and editor; Pat Worthington wasalso central to this book’s success by sharing her spe-cialized knowledge of nursing applications and herorganizational skills, efficiency, and editorial prowessresulting in her ability to produce high-quality chap-ters well in advance of deadlines; Mark DeLegge’smedical expertise and quick wit were virtues of dis-tinction as he skillfully coauthored the chapter onHome Care while aggressively reviewing other manu-scripts in a scholarly and timely manner; and finally,I was also blessed to work with Todd Mattox, ourpharmacy expert whose enthusiasm, intelligence, andincredible attention to detail never faltered while hemultitasked as coauthor of the chapter on Cancer ontop of his many responsibilities as Associate Editor.All four of these exceptional individuals consistentlyexceeded my expectations in their quest for excellenceby their dedication, meticulous editing, perseverance,resourcefulness and infinite effort—at times underconsiderable pressure. It was a pleasure to have hadthe opportunity to work with them.

On behalf of the Associate Editors and myself, werecognize the many people whose help contributed tomaking this publication happen! Our sincere appreci-ation is extended to each of our extraordinary authors,who, in the midst of their very busy lives took on onemore project for us. We certainly have enjoyed a won-derful professional relationship as well as friendshipfor years with many of these authors, and we believethat because of each of their efforts in crafting state-of-

the-art chapters, we have successfully amassed a trulyeffective core curriculum from the nation’s preemi-nent nutrition support experts.

We also thank our reviewers for their constructivecomments. Without their suggestions an objectivecore curriculum representing interdisciplinary needscould not have been possible. This publication alsobenefited immensely from Jennifer Wooley’s com-prehensive review of the entire document. We like-wise wish to recognize the expert editing performedby Wanda Hain-Howell to the Test Your Knowledges e c t i o n s .

Tremendous tribute is directed to our many prede-cessors who contributed to earlier A.S.P.E.N. core cur-ricula. Much advice, insight, expertise, and assistancehave been provided by numerous authors, reviewers,and editors over the years. Special acknowledgment toprevious curricula editors: Trisha Fuhrman, BeverlyHolcombe, Doug Seidner, Kathy Hammond, EvaShronts, Laura Matarese, Christine Kennedy-Caldwell,Peggi Guenter, Kathryn Hennessy, Marsha Orr,Michael Christensen, and Barbara McKinnon.

The support of the American Society for Parenteraland Enteral Nutrition staff as well as Shriners Hospi-tals for Children is gratefully acknowledged withemphasis on the important contributions of RobinKriegel, Debra Ben Avram, and Sandra Smith. A veryspecial, heartfelt thanks to Peggi Guenter who is theengine that drives A.S.P.E.N. nonjournal publica-tions. Peggi was instrumental in this project’s successbecause of her effectiveness in marshalling the manyadministrative details of production, resource manage-ment, contracts, and timelines. Peggi also impressedme with her diligence, diplomacy, efficiency, andcountless ideas as she applied her mastery of wordprocessing, as well as her broad knowledge of bothnutrition support and the publication process to thisv e n t u r e .

xxiii

Acknowledgments

Finally, the great interest, encouragement, andvaluable suggestions received from our respective col-leagues, friends, and families throughout the past 2years of this endeavor were invaluable for this book’sevolution and fruition. Special recognition for theirpatience, love, and overwhelming support is extended

to Bill Barkalow, my parents, and my children forbeing such gifts from God.

Michele M. GottschlichEditor-in-Chief

xxiv A C K N O W L E D G M E N T S