Presentation Title: "Dysautonomia, Dysmotility, and Dysbiosis: Challenges and Alternatives When Providing Nutrition Care"

1. Gabriela Gardner RD-AP, LD, CNSC. Clinical Dietitian, Memorial Hermann Hospital - Texas Medical Center, Houston, TX “I have no commercial relationships to disclose”

2. Karen Martin, MA,RDN,LD,FAND. Regional Clinical Dietitian, Amerita Specialty Infusion, San Antonio, TX. Neuromuscular Dietitian, UT Health--San Antonio, TX Amerita affiliation: salary--presentation will not include commercial information and is based on evidence-based science

Presentation Overview/Summary Dysautonomia encompasses various medical conditions that involve symptoms such as fainting, unstable blood pressure, and abnormal heart rate. Patients who suffer from dysautonomia present with extensive gastrointestinal (GI) symptoms and inability to take enough nutrition and/or hydration orally. Severity of GI symptoms can translate in the development of malnutrition and micronutrient deficiencies. Adult and Pediatric case studies will be presented highlighting the evaluation and treatment followed including oral, enteral, and parenteral nutrition.

Learning Objectives At the conclusion of the presentation, the learner will be able to: 1. Understand the relationship between autonomic dysfunction and the development of GI dysfunction 2. Recognize how GI symptoms impact nutritional status; likely resulting in malnutrition 3. Identify nutrition therapies to optimize care in patients dysautonomia including oral, enteral, and parenteral nutrition

Key Takeaways/Fast Facts • Patients with autonomic dysfunction usually have digestive problems related to dysfunction of the parasympathetic nervous system. Severity of GI symptoms can lead to malnutrition. • Clinicians will gain knowledge on therapies that can be used to improve dysautonomia symptoms, fluid balance, and nutritional status.

Learning Assessment Questions 1. Patients with autonomic dysfunction can experience the following, except: a) hypomotility, resulting in nausea and vomiting b) small bowel bacterial overgrowth c) high levels of B12 d) decrease in blood pressure and increased heart rate 2. What are the main dietary factors to aid in the management of autonomic dysfunction a) fluid and potassium intake b) fluid and salt intake c) potassium and salt intake d) potassium, phosphorous, and magnesium intake 3. Patients with autonomic dysfunction are NOT at risk of malnutrition a) True b) False 4. The constellation of symptoms associated with dysautonomia may occur a) slowly, without an inciting event b) following an acute infection or injury c) related to autoimmune disease or Ehlers Danlos syndrome d) All the above 5. Patients with dysautonomia may experience challenges maintaining lean body mass and experience exercise intolerance related to ALL BUT: a) decreased perspiration b) orthostatic intolerance c) laziness d) progressive exercise program starting with horizontal activities such as swimming with a paddleboard

Learning Assessment Answers: 1. Answer = C; Rationale: GI dysfunction is common in patients with dysautonomia. Common symptoms include nausea, vomiting, diarrhea, constipation, early satiety, bloating, gas, and difficulties swallowing. Patients can also experience increase in heart rate and drops in blood pressure. B12 may be depleted due to inadequate oral intake and/or small bowel bacterial overgrowth 2. Answer = B; Rationale: Fluid and salt intake are the primary dietary interventions to aid in the management of autonomic dysfunction 3. Answer = B; Rationale: Patients with dysautonomia are at increased risk of malnutrition related to severity of GI dysfunction. Many patients have decreased oral intake and/or malabsorption leading to unintentional weight loss and moderate to severe muscle and fat depletion 4. Answer = D: Rationale: Patient’s with autonomic dysfunction may present in a variety of ways, and may be associated with other diagnoses including Fabry’s disease and Ehlers Danlos. 5. Answer = C; Rationale: Patients with autonomic dysfunction may not perspire and experience significant POTS and other negative feedback symptoms with traditional activities. They may benefit from a modified exercise program.

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