嗜好に合った「おいしい栄養補助食品」を提供し栄養状態の改善でリハの目標達成をめざす 一般社団法人 是真会 長崎リハビリテーション病院 （長崎県長崎市） 在宅復帰や日常生活動作の最大限の改善などの長期目標をめざして、 日々の栄養管理に取り組んでいる長崎リハビリテーション病院。 急性期よりも在院日数が長くなる分、嗜好が喫食量に影響し、 ひいては栄養状態を左右することもあるという。 同院において、甘さが苦手な患者へ嗜好に合った栄養補助食品を提供し、 栄養管理が奏功した事例を紹介する。 栄養補助食品で対応するが甘い味が苦手な患者に苦慮 長崎市の中心部、商店街の一角に位置する長崎リハビリテーション病院。同院は１４３床からなる回復期リハビリテーション（回リハ）病院であり、そのすべての病棟において入院料１を算定している。

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がん患者様が取り入れられる栄養ケアや運動（動画QRコードあり）について、手術前～手術直前・直後～化学用療法中に分けてご紹介しています。栄養指導でのご活用や、患者様とのコミュニケーションツールとしてもお使い頂けます。

乳清たんぱく含有飲料による早期栄養介入の推進 ICUにおける早期経口摂取の課題 令和2年度の診療報酬改定で特定集中治療室（以下、ICU）において早期栄養介入管理加算（1日につき400点）が新設されました。これはICU入室から48時間以内に管理栄養士が介入して栄養投与を開始した場合、そうでない場合と比較して、「死亡率の低下」、「ICU在室日数の短縮」、「平均在院日数の短縮」が見られるというエビデンスに基づいた改定です。疑義解釈資料で48時間以内の経口摂取でも算定できるとされています。当院でも飲水は許可されても、経口・経腸栄養実施が48時間を越え、早期栄養介入のできない患者さんもいらっしゃいます。これは患者さんが食欲不振や摂食嚥下障害を示すこと、また消化管吻合部への負担を考え、早期経口摂取を望まれない外科の先生方もいらっしゃるからです。Oral Nutrition Supplementation（以下、ONS）の適切な活用が望ましいのですが、従来のONSは脂質や食物繊維などの残渣が多いものも多く、味も濃厚なため、患者さんや外科の先生方の理解が得られないケースや、アドヒアランスに課題があることが多くありました。 乳清たんぱく含有飲料の検討 製品導入前に外科の先生方に「乳清たんぱく含有飲料」（200kcal、たんぱく質10g、脂質0g/本）を試飲してもらったところ、美味しくて飲みやすいと高い評価を得ました。また、原材料がたんぱく質、炭水化物のみで構成され、エネルギーは200kcal/本あり食事として扱えます。一日の唾液量が750ml-1500ml/日程度であることを考えると、飲水の許可があれば「乳清たんぱく含有飲料」を飲んでも残渣も少なく、吻合部への負担も少ないと考えられます。日本版重症患者の栄養療法ガイドラインでは、術後の積極的なたんぱく質摂取が推奨されており、吸収効率の良い乳清たんぱく質を摂取することは、臨床上も意義があると考えます。

はじめに 監修 医療法人 協和会 第二協立病院 栄養科 科長 飛川　千歳先生 医療法人 協和会 第二協立病院 言語療法科 科長代理 恩田　光平先生 飛川 医療法人協和会　第二協立病院は、人工透析センターを含む一般病床、回復期リハビリテーション病棟、障害者病棟、産科病棟、緩和ケア病棟など、現在425床を有する回復期・慢性期の病院です。患者さんは主に兵庫県川西市および阪神北圏域から受診されており、当院は地域の皆様および急性期病院のご支援のもとに、医療・看護・介護を提供しています。 当院はこれまで回復期リハビリテーションが中心の施設であり、急性期の治療が終了し病状が落ち着いてから来院されるのが通常でしたが、コロナ禍以降、急性期の治療終了後まもなく回復期に移行して来られる患者さんが増加傾向にあります。 そして経鼻経管栄養や胃ろうの方、特に消化態栄養剤を経鼻のまま使って来られる方など、重症患者さんが多くなっている印象があります。 恩田 患者さんの年齢層は70〜90歳代で平均80歳くらいのご高齢の方が多いです。当院に入院時から独歩、杖歩行、車椅子移動の患者さんはいますが、体を起こすことから始める患者さんも少なくありません。医療度や介護度の高い患者さんが増えています。また認知症を合併している方も多い印象を受けます。 経口摂取をされている患者さんは、前院からの情報を参考にしながら、入院当日に食事形態を評価します。経鼻経管栄養や胃ろうの方は、改訂水飲み検査などの嚥下スクリーニングの後、ゼリー食やミキサー食から食事を始めますし、訓練から開始する患者さんもいます。 飛川 入院後、数日間の喫食状況と採血データなどから、食事内容を決めることになりますが、嚥下食やハーフ食の提供になる方が、私が着任した3年前に比べ1〜2割増えている印象です。普通量を全量食べられない場合は、不足分を補助食品で補うことになります。また喫食量が半分以下の場合はハーフ食に栄養補助食品をプラスした食事や個別対応の食事に切り替えることになります。 「200kcal/100ml MCT含有栄養補助飲料」活用のメリット 患者さんのメリット 飛川　千歳先生 残さず飲み切りやすい 患者さんの負担を軽減した飲み切りサイズで、高カロリーの栄養補給が可能です。 嚥下回数を減らせる可能性があります。 飛川 「200kcal/100ml MCT含有栄養補助飲料」は少量なので、喫食量の少ない患者さんにとって飲む負担が軽減され、飲み残しが減ったと実感しています。嚥下障害の方にはとろみをつけたり、ゼリーに加工していますが、少量なので喫食は良好です。 糖質割合に配慮した栄養補給が可能 血糖コントロールが必要な方では糖質割合に配慮した栄養補給が可能です。 飛川 脂質中にMCTを約30%含み、エネルギー比率は一般的な栄養補助飲料の糖質割合が約60%であるのに対し、｢200kcal/100ml MCT含有栄養補助飲料｣等は48%であり、糖質割合に配慮した組成となっています。 そのため、糖質への配慮が必要な方にも勧めやすくなりました。 @charset "UTF-8";.c-btn{-ms-flex-align:center;align-items:center;border-radius:70px;box-sizing:border-box;color:#fff;cursor:pointer;display:-ms-inline-flexbox;display:inline-flex;font-family:"Noto Sans JP",sans-serif;font-size:16px;font-weight:500;-ms-flex-pack:center;justify-content:center;letter-spacing:.05em;line-height:1.2em;position:relative;text-align:center;text-decoration:none!important;transition:all 250ms ease}.c-btn[disabled]{background:#d4d4d4;border-color:#d4d4d4;pointer-events:none}.c-btn--large{height:70px;width:275px}@media screen and (max-width:767px){.c-btn--large{max-width:275px;width:100%}}.c-btn--center{display:-ms-flexbox;display:flex;margin:0 auto}@media screen and 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長期の経腸栄養管理患者では、消化管機能の低下や腸内細菌叢の変化により吸収能低下や消化器症状が惹起されます。ホエイペプチドとプレバイオティクスのWアプローチにより、経腸栄養の不耐症リスクの低減が期待できます。