1. Reduced risk of complications, such as infections
2. Specialist weight management for obesity with cirrhosis
2.1. Individualised support to achieve a high protein, low energy cirrhotic eating pattern to promote weight loss whilst avoiding sarcopenia
3. Educate, train and support other healthcare professionals
3.1. Non-specialist dietitians
3.2. Student dietitians
3.3. Nurses
3.4. Healthcare assistants
3.5. Dietetic assistants
3.6. Doctors
3.7. Other AHPs
3.8. Transplant referral centre/satellite hospital dietitians
4. Progress nutrition care of hepatology and liver transplant recipients locally, nationally and internationally
4.1. National and international hepatology dietitian, AHP, nurse and MDT networks and committees
4.2. Research & audit
4.3. Guideline development
4.4. Multiprofessional conference presentations and workshops (e.g. BASL/BLTG)
5. Post-transplant care
5.1. Short-term - inpatient care and recovery
5.1.1. Nutrition support through diet, oral supplements, tube feeding and PN
5.1.1.1. Specialist critical care nutrition support
5.1.1.2. Managing catabolism
5.1.1.3. Recovery and anabolism
5.1.2. Treat/manage complications
5.1.2.1. Chyle leak
5.1.2.2. High blood glucose
5.1.2.3. High potassium
5.1.2.4. Poor appetite, nausea, taste changes
5.1.2.5. Support with managing excess hunger, e.g. due to steroids and recovery of appetite
5.1.3. Wound healing
5.1.4. Prevention and treatment of malnutrition, sarcopenia and frailty
5.1.5. Food safety and hygiene
5.1.6. Liaise with, support and hand over to liver transplant satellite dietitians
5.2. Long-term
5.2.1. Healthy lifestyle support to reduce the risk of obesity, CVD, cancer, oesteoporsis
5.2.2. Treatment of dyslipidaemia, hypertension, obesity, diabetes, oesteoporosis, gout, renal impairment
5.2.3. Recurrence of liver disease and malnutrition
6. Specialist dietary/nutritional counselling skills
6.1. Patient centred care
6.2. Facilitating and empowering patients to make lifestyle changes
6.3. Support families and carers
6.4. Nutrition education for patients and their families/carers
6.5. Motivational interviewing
6.6. SMART goals
6.7. Balancing overall treatment burden with benefits
6.8. Supporting food enjoyment, social aspect of eating as well as meeting medical nutrition needs
6.9. Produce patient resources
7. Collaborate and communicate with multidisciplinary team
7.1. Advocate
7.1.1. Communicate nutrition diagnoses, dietetic concerns and plans
7.2. Collaborate to balance overall treatment burden with benefits
7.3. Recommend medication changes, e.g. Creon, anti-emetics
7.4. Signpost and enable access to other services - OT, PT, food banks, community support, charities, patient support groups
8. Improve outcomes
8.1. Improved quality of life, wellbeing, functional ability
8.2. Prevent admissions
8.3. Reduce length of stay
8.4. Improved fluid retention and encephalopathy
8.4.1. Reduced frequency of paracentesis
8.5. Improved nutritional status, muscle mass and frailty
8.6. Reduced risk of death
9. Evidence-based practice
9.1. Understand and critically appraise evidence
9.2. Translate evidence into clinical care
9.3. Communicate evidence with patients and other healthcare professionals
9.4. Work with uncertain evidence
9.5. Identify gaps in the evidence base to inform research priorities
9.6. Lead research - planning, securing funding and completing research to help fill evidence gaps
9.7. Use evidence to influence practice guidelines and policy
10. Quality improvement
10.1. Service evaluation
10.2. Audit
10.3. Research
10.4. Service improvement
11. Use of specialist products to meet complex nutritional requirements
11.1. Dietary intake, oral nutritional supplements, nasogastric feeding, nasojejunal feeding, parenteral nutrition
11.1.1. Low potassium
11.1.2. High energy, high protein
11.1.3. Low volume
11.1.4. Moderate carbohydrate (diabetes)
11.1.5. 50g carbohydrate at bedtime
11.1.6. Medium chain triglycerides
11.1.7. Low fat
11.1.8. Low energy, high protein
12. Assess and diagnose malnutrition, sarcopenia and frailty
12.1. Assess nutritional intake
12.2. Detailed arm anthropometry and handgrip due to fluid overload and importance of muscle mass for outcomes
12.3. Weight history
12.4. Adjust weight for fluid retention - clinical examination, paracentesis fluid weights, imaging
12.5. Validated diagnosis tools - RFHGA, LFI etc.
12.6. Identify micronutrient deficiencies
13. Treat/manage complications
13.1. Low fat diet for chyle leak
13.2. Low potassium /phosphate diet with renal dysfunction
13.3. Low fat diet for bile malabsorption
13.4. No added salt for ascites
13.5. Fluid restriction for severe oedema and low sodium
13.6. Prevent and manage refeeding syndrome - gradual introduction of nutrition, vitamin supplementation and electrolyte monitoring and replacement
13.7. Diabetes/ liver disease and post transplant hyperglycaemia management
14. Monitor and treat malnutrition, sarcopenia and frailty
14.1. Cirrhotic eating pattern
14.1.1. 5-6 carbohydrate containing meals/snacks per day
14.1.2. 50g carbohydrate bedtime snack
14.1.3. 4+ sources of protein per day
14.1.3.1. High energy, energy balanced or low energy
14.2. Estimate nutritional requirements
14.2.1. Liaise with Doctors & Pharmacists regarding micronutrient deficiency treatment
14.2.2. Elevated energy and protein requirements
14.2.3. Adjust for obesity, malnutrition, metabolic stress and malabsorption
14.3. Symptom management
14.3.1. Early satiety
14.3.2. Poor appetite
14.3.3. Nausea and vomiting
14.3.4. Diarrhoea
14.3.5. Constipation
14.3.6. Steatorrhoea
14.3.7. Weight loss
14.3.8. Encephalopathy
14.3.9. Ascites
14.3.10. Taste changes
14.4. Identify, diagnose and treat malabsorption
14.4.1. Pancreatic enzyme insufficiency
14.4.1.1. Pancreatic enzyme replacement therapy (e.g. Creon) dose adjustment and education about optimal use
14.4.2. Fat malabsorption with bile insufficiency
14.4.3. Requirement for further investigation - bile salt malabsorption, small bacterial overgrowth
14.5. Hand over assessment and support referral-centre/satellite hospital dietitians
14.6. Monitor nutritional intake
14.7. Monitor nutritional status including detailed arm anthropometry and handgrip
15. Reverse NAFLD
15.1. Diet counselling
15.2. Exercise counselling
16. Dietary management of other conditions common in patients with liver disease
16.1. Ulcerative colitis
16.2. Crohn's disease
16.3. Coeliac disease
16.4. Osteoporosis
16.5. Diabetes
16.6. Obesity
16.7. IBS
17. Prevent malnutrition, sarcopenia and frailty
18. Areas
18.1. Hepatology
18.1.1. Acute illness
18.1.2. Chronic illness
18.1.3. Reverse/halt disease
18.1.4. Palliative care
18.2. Liver transplant
18.2.1. Liver transplant assessment
18.2.2. Prehab/optimisation to be suitable for transplant
18.2.3. Prehab/optimisation whilst waiting for transplant
18.2.4. Post-transplant
18.2.4.1. Rehab
18.2.4.2. Long-term health
18.2.4.3. Future illness