Case 15- Nutrients 2 Flashcards
Malnutrition university screening tool (MUST)
5 steps that test risk of undernutrition
• BMI
• Unplanned weight loss over 3-6 months
• Acute disease effect- if patient is acutely ill and has had no nutritional intake for over 5 days or is likely to be, then you add 2 points.
• Determine overall risk of malnutrition by calculating the score, 0 is low risk, 1 is medium risk, 2 or more is high risk
• Action- determined by local agreed protocol.
Anthropometry- weight and percentage weight (Screening nutritional status)
A patient is indicated for nutrition support if they have:
1) BMI<18.5kg/m2 unintentional weight loss of >10% in the previous 3-6 months
2) BMI<20kg/m2 and unintentional weight loss >5% in the previous 3-6 months
Calculating BMI
BMI (kg/m^2) = weight (kg) / height^2 (m^2)
Anthropometry- BMI (screening for nutritional status)
If BMI <18.5kg/m2 patient is underweight
If BMI 18.5-25kg/m2 patient is in normal BMI range
If BMI >25kg/m2 patient is overweight
Anthropometry- mid upper arm circumference MUAC (screening for nutritional deficiencies)
Measuring the circumference of the mid point of the upper arm using a tape measure, measures mass. Useful if a person cant be weighed or their weight is not a true reflection of body mass i.e. ascites.
If MUAC is <23.5cm the patient is likely to have a BMI <20kg/m2 and may be at risk of malnutrition.
Anthropometry- skinfold thickness (nutritional screening)
Used by a trained person using skinfold callipers which have been Calibrated. Can be done at 8 different sites but most commonly the tricep skinfold (TSF). Measurements should be duplicate, longitudinal measurements identify changes in fat mass.
Centile tables are used for interpretation
Anthropometry- Mid arm muscle circumference MIAMC (nutritional screening)
MAMC is a surrogate measure of fat free mass and is calculated using MUAC and TSF (tricep skin fold thickness).
MAMC (cm) = MUAC (cm) – 3.14 x TSF (cm)
Centile tables allow measurements of changes in total body muscle mass over time
Nutritional screening- bloods
1) Haemoglobin- assess iron status, anaemia
2) Glycated haemoglobin (HbA1c)- indicates average blood sugar over a couple of months
3) Sodium- indicates hydration status and kidney function
4) Urea- high urea may indicate dehydration
5) Calcium and Phosphate- used when assessing refeeding risk, calcium is adjusted for albumin levels
6) Magnesium- low if large GI losses
7) Micronutrients- vitamins and trace elements, best measured when CRP is low as affected by infection
Nutritional screening- Clinical assessment
Diseases can cause malnutrition through increased energy requirements, reduced energy intake or increased nutritional losses. These include: Cancer, COPD, Heart failure, Crohns, liver disease, stroke, motor neurone disease, mental health issues and trauma.
Symptoms include- altered bowel movements, upper GI upset i.e. nausea, early satiety, dysphagia, lethargy.
Nutritional screening- dietary assessment
Assess nutritional requirements. In the dietary assessment you would look at the quantity and quality of food and fluid intake. As well as eating patterns, portion size, cooking methods and nutritional supplements taken.
Nutritional support- Environmental assessment
Social- ability to shop and cook. Do they need assistance with eating and drinking. Their mobility, budget restraints, limited storage facilities, meal timings and family support.
Physical- appetite, dentures, dexterity, use of cutlery, taste change, nausea, heart burn, bloating, early satiety, diarrhoea, constipation, breathing difficultes, dysphagia, food intolerances, diminished thirst and taste preference.
Refeeding risk assessment- only need one factor
- BMI- less than 16 kg/m^2
- Weight loss- unintentional weight loss greater than 15% within the last 3-6 months
- Nutritional intake- little or no nutritional intake for more than 10 days
- Blood biochemistry- low levels of potassium phosphate or magnesium prior to feeding
Refeeding risk assessment- when the patient has 2 or more of the following factors:
- BMI less than 18.5kg/m^2
- Unintentional weight loss greater than 10% within the last 3-6 months
- Little or no nutritional intake for more than 5 days
- A history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics
Treatment for chronic undernutrition
- Parenteral- delivery of nutrition intravenously
- Enteral- delivery of nutritionally complete feed directly into the gut via a tube
- Oral nutritional support- additional snacks, fortified food (adding nutrients to a particular food), oral nutritional supplements.
Types of fortification
- Mass fortification- general public, iron in breakfast ceral
- Targeted fortification- specific populations
- Market driven fortification- Business orientated initiative
Food fortification- what foods are given to patients lacking certain macronutriensts
- Energy (carbohydrate)- sugar, jam
- Energy (fat)- cream, butter, cheese, crème fraiche
- Protein- skimmed milk powder to milk, peanut butter
Oral nutritional supplements
- Milkshake type- nutritionally complete
- Juice-based- not nutritionally complete as no fat
- High energy powders i.e. complan and meritene- not nutritionaly complete
- Semi-solid/dysphagia ranges- thickened liquids through to puddings
- High protein- jellies, shots and milkshakes
- Low volume high concentrate- fat and or protein based products
Parenteral nutrition
Using the blood stream, via central or peripheral route. Central route is preferable as you can have more concentrated feeds but tends to be used for more long term access. Peripheral access is more short term, a PIC (periphery inserted central catheter) line can be used for concentrated food stuff as its connected to the central system.
In order to keep the gut healthy there should be some enteral nutrition even if they are relient on Parenteral
Types of enteral nutrition
You can use a nasogastric tube, gastronomy tube, nasoduodenal tube etc. These tubes can be divided into gastric or post pyloric. They can be short term or long term. The Gastrostomy and Jejunostomy tube are more long term. Some feeds are more concentrated then others. Need to be fed through a pump to ensure they are not getting too much at once.
Process of starvation
- Levels of glucose begin to fall- 24 to 72 hours, Glucagon is released and Insulin is reduced
- Glucose levels maintained by Glycogenolysis- Glycogen rarely lasts more then 72 hours
- Gluconeogenesis occurs- preferred fuel for brain, falls between 24-72 hours
- Fatty acid oxidation in the liver hepatocytes- produces ketone bodies
- BMR is reduced by reducing the action of cellular pumps- electrolytes leak across the cell membrane. Increase in extracellular water and sodium with depletion of total body K+, Mg+2 and Phosphate. Serum concentration of ions are maintained whilst intracellular stores are depleted. Na+ and fluid leak into the cell causing Na+ intolerance. Micronutrient store is depleted and thiamine deficiency is likely
Refeading pathogenesis
- In the precense of food there is a conversion to glucose as the major energy source. There is a rapid decline in gluconeogenesis and anaerobic metabolism. Insulin starts to increase, this activates the ATP pump which requires magnesium as a cofactor. Drives K+ into the cells and Na+ and fluid out of the cells. Phosphate is driven into the cell as its required for energy storage as ATP
- Causes cellular uptake of glucose, potassium, magnesium and phosphate and a decrease in extracellular concentrations. Biochemical refeeding.
- Thiamin deficiency can also occur as it’s a coenzyme in carbohydrate metabolism
Issues the patient will have if they get refeeding syndrome
- Hypophosphataemia
- Hypokalaemia
- Hypomagnesaemia
- Reduced sodium and water excretion- the extracellular fluid compartment expands
- Vitamin deficiencies- particularly thiamine
Cardiac effects of refeeding syndrome
Low PO4- altered myocardial function, arrhythma, congestive heart failure, sudden death
Low K- Arrhythmia, cardiac arrest, ECG changes
Low Mg- Arrhythmia, tachycardoa
Respiratory effects of refeeding syndrome
Low PO4- acute ventilatory failure, dyspnea
Low K- respiratory depression
Low Mg- respiratory depression
Hepatic effects of refeeding syndrome
Low PO4- liver dysfunction
Low K- exacerbation of hepatic encphalopathy
Renal changes with refeeding syndrome
Low PO4- acute kidney injury, bicarbonate and glucose wasting, acute tubular necrosis
Low K- decreased urinary concentrating abilities, polyuria, polydipsia, decreased eGFR
Low Mg- increased potassium loss secondary to hypokalaemia
Gastrointestinal affects of refeeding syndrome
Low PO4- anorexia, nausea and vomiting
Low K- constipation, nausea and vomiting
Low Mg- abdo pain, nausea and vomiting, anorexia
Neuromuscular affects of refeeding syndrome
Low PO4- lethargy, weakness, paralysis, confusion
Low K- paralysis, rhabdomyolysis, weakness
Low Mg- ataxia, confusion, coma
Haemotological affects of refeeding syndrome
Low PO4- haemolytic anaemia, red blood cell dysfunction, haemorrhage, thrombocytopenia
Haemotological affects of refeeding syndrome
Low PO4- haemolytic anaemia, red blood cell dysfunction, haemorrhage, thrombocytopenia
Metabolic affects of refeeding syndrome
Low PO4- reduced oxygen release to tissues from haemoglobin
Low K- glucose intolerance, metabolic acidosis
Low Mg- hypocalcemia, hypokalaemia
Refeeding syndrome- thiamine deficiency
1) Congestive heart failure
2) Cardiomegaly
3) Pulmonary oedemia
4) Pleural effusion
Refeeding syndrome- fluid retention
1) Congestive heart failure
2) Pulmonary oedema
3) Respiratory depression
4) Fatty liver
Preventing and managing refeeding syndrome
- Restoration of circulatory volume
- Provision immediately before and during the first 10 days of feeding- oral thiamine 200-300mg daily. Vitamin B co-strong 1 or 2 tablets 2 to 3 times a day. Or IV vitamin B. Balanced multivitamin, trace element supplements.
- Low dose and slow introduction of nutrition- too much can cause vomit, don’t want electrolyte shifts
- Supplements of Potassium (2-4 mmol/kg/day), Phospate and Magnesium. Doesn’t have to be before feeding can be concurrently. Monitor levels
What the patients nutritional balance should be after starvation
You slowly increase the patients calory intake. Should be 50-60% carbohydrates, 30-40% fat and 15-20% protein. If vitamins drop you shouldn’t up the calories.
Monitoring refeeding syndrome
- Anthropometry- change in body weight
- Bloods- U&E’s, blood glucose levels, phosphate, magnesium and corrected calcium
- Clinical- ECG monitoring, blood pressure and pulse rate, nausea and vomiting, fluid intake and output, Urinalyses, Stool charts
- Dietary- feeding rates
Plant based diet
Few or no animal products. Can support healthy living at every age and life-stage if it is well planned. Reduces the risk of being overweight or obese and protects against cancer/CVD. Need to be well balanced
Types of plant based diets
- Lacto-ovo vegetarians= eat dairy food and eggs but not meat, poultry or seafood
- Ovo-vegetarians= include eggs but avoid all other animal foods, including dairy
- Lacto-vegetarians- eat dairy foods but exclude eggs, meat, poultry and seafood
- Vegans- don’t eat any animal products, including honey, dairy and eggs
- Pescetarians or semi-vegetarians (flexitarians)
Nutrients that vegetarians may be deficient in
- Calcium- dried fruit
- Omega 3 fatty acids- walnuts and flaxseed oil
- Iodine- seaweed
- Vitamin B12- 10mcg supplements, fortified cereals
- Iron- green leafy vegetables
- Vitamin D (fortified foods like vegetable spread. For vitamin D there is a 10mcg/day supplement during autumn and winter months.
- Zinc- phytates in plant foods reduce zinc absorption, fermented soya
- Selenium- grains, seeds and nuts
- Protein- lentils, beans
Nutrients that vegetarians may be deficient in
- Calcium- dried fruit
- Omega 3 fatty acids- walnuts and flaxseed oil
- Iodine- seaweed
- Vitamin B12- 10mcg supplements, fortified cereals
- Iron- green leafy vegetables
- Vitamin D (fortified foods like vegetable spread. For vitamin D there is a 10mcg/day supplement during autumn and winter months.
- Zinc- phytates in plant foods reduce zinc absorption, fermented soya
- Selenium- grains, seeds and nuts
- Protein- lentils, beans
Medical based diet
- Milk allergy/lactose intolerance- avoid milk, cheese, butter
- Coeliac disease- avoid products containing wheat, barley, rye and oats. Calcium deficiency common
- Nut allergy
- Diabetes- eat starchy foods at regular intervals, avoid foods high in sugar
- Low fat diet- avoid cheese, bacon etc. May have gallstones or CVD risks
- Low salt diet- renal disease, limit processed food
Nutritional requirements pre-pregnancy
Folate supplements should be given to women. Both women and men should stop drinking and smoking to maximise fertility. The consumption of selenium (brazil nuts, tuna), zinc (oysters, beef) and long chain omega-3 fatty acids (salmon, walnuts) should all be encouraged as they are all important for sperm, testosterone and prostaglandin production respectively.
Micronutrients to take during pregnancy
- Vitamin D (10 micrograms a day)- use supplements, prevents rickets
- Calcium- 1g daily, used for development of babies bones, requires 30g over the whole of the pregnancy, taken from mums bone reservoir (1000g)
- Iron- an increase is needed due to maternal haematopoiesis, foetal haematopoiesis and fetal hepatogenesis. No specific interventions are required only be aware in Iron deficiencies
- Avoid vitamin A due to foetal abnormalities
- Long chain omega 3 fatty acids- useful for CNS and retina development, eat 2 portions of fish a week, one of which is oily.
- Avoid alcohol
- Caffeine should be reduced to 200mg/day
- Avoid raw meat
Pregnancy- increasing calorific intake
The average women puts on 12.5kg during pregnancy. Women should increase their calorific intake by 200kcal/day during pregnancy. Under-nutrition can cause intra-uterine growth restriction. Over-nutrition can cause macrosomia and gestational diabetes.
Change from colostrum to normal breast milk
In the first 2 days Colostrum is produced, poor in macronutrients but contains components of the baby’s immune system. Breast milk then changes over 7-21 days and becomes rich in water, lactose and fats. Breast feeding reduces SIDS, childhood leukaemia and obesity in adults.
Componments of formula milk
The main componments is whey and casein protein, the high levels of proteins and lack of immune support is the main difference between breast and formula milk
Weaning
The gradual introduction of solid food to an infants diet, begins at 6 months. At first little nutritional content will be delivered by solid food and milk feeding should continue
Food for weaning infants
Starchy foods such as bread/rice/pasta, dairy products such as cheese/yogurt, fruit/vegetables and cooked meat/fish/eggs/pulses/beans. These are all nutritious and easily chewable foods. All should be chopped or minced as remember babies do not normally have teeth.
Foods to avoid in infants
The immune system is still poorly developed before 6 months so gluten, eggs, seafood and unpasteurized dairies should be avoided. Whole nuts should be avoided due to choke risk. Fo children aged 6 months to 4 years, receiving less than 500ml of milk a day, they should receive healthy start vitamins.
Nutritional requirements for toddlers
High calorie requirements relative to size. Small meals with frequent snacks, High density of protein, vitamins and minerals. Require proportionally higher levels of iron than adults
Nutritional requirements 2-5
High fat diet is recommended i.e. in dairy and oily fish. Saturated fats remain unhealthy. Sugar should be avoided such as in sweets or cakes. Fruit juices should be diluted for under 5’s due to high sugar and low fibre. Salts should not be added to foods as kids may develop a taste. Should have full fat milk, not recommended in other groups
Adolescence nutritional requirements
Increased iron due to menstruation and increased muscle mass. Females require an average of 14.8mg of iron daily depending on menstrual flow, whereas males require 11.3mg. Vitamin C facilitates iron absorption in the body, adolescents require more than adults with 1000mg/day for males and 800mg/day for females.
Adolescence nutritional requirements
Increased iron due to menstruation and increased muscle mass. Females require an average of 14.8mg of iron daily depending on menstrual flow, whereas males require 11.3mg. Vitamin C facilitates iron absorption in the body, adolescents require more than adults with 1000mg/day for males and 800mg/day for females.
Eatwell nutritional recomendations for adults
Males should aim to consume 2500 calories a day and women should consume 2000 calories, to maintain a BMI between 18.5 and 24.9. BMI is weight (kg) / height squared (m^2). We are expected to consume 5 portions of fruit and vegetables per day, where 1 portion equals 80g. It is again advised to consume 2 portions of fish, one of which is oily.
Reference daily intake for adults
Energy- 2000kcal Total fat- 70g Saturated fat- 20g Carbohydrates- 260g Sugars- 90g Protein- 50g Salt- 6g
The percentage of people are obese
26% of men and 24% of women are obese
Types of Iron
Haem forms are found in meats and easily absorbable. Non-haem forms are found in plants and are less readily absorbed. Vitamin C helps this process.
Nutritional requirements for the over 50’s
Calorie requirements decrease due to a physiological reduction in muscle mass and reduced exercise levels. The over consumption of calories is still the most common nutritional abnormality. Undernutrition can also be an issue due to chronic conditions including oesophageal or neurological diseases. Poverty in pensioners can reduce access to healthy foods.
Vitamin D deficiency is common as elderly skin is less able to convert vitamin D to its active form
Vitamin deficiencies is the developed world
Rickets is fairly common, mild deficiencies are common I.e. iron, vitamin D, vitamin B12, folate and Iodine
Deficiencies in the developing world
Iodine, Iron and vitamin A deficiencies
Vitamin A deficiency
- There are two types of vitamin A: retinoids (preformed vitamin A) and carotenoids (proformed vitamin A).
- Both types are converted to retinol (ROH) by the liver. There, it’s either stored or transported by the lymphatic system to cells throughout the body.
- Symptoms of vitamin A deficiency- night blindness, lesions on cornea, blindness (xerophthalmia), increased susceptibility to infection, decreased immune function, impaired reproduction, development and growth.
Vitamin A deficiency- stages of Xerophthalmia
• Conjunctival xerosis- dryness loss of goblet cells
• Bitot’s spot- mound of keratinised cells
• Corneal scar
• Xerophthalmic fundus- white spots, lesions on retina
Formed due to abnormal dryness of the conjunctiva and cornea of the eye with inflammation and ridge formation
Vitamin A deficiency- Night blindness
Insufficient Retinol reaching eyes reduces amount of rhodopsin, cant see in poor illuminations, increased time between bleaching of rods and seeing clearly, failure of pupils to constrict normally in low illuminations.
Vitamin A deficiency- Immune system
Impaired maintenance of epithelial tissue i.e. in the gut may enable further infection, increased keratinisation and decreased mucus, decreased ability to repair damaged epithelial tissue. Impairs neutrophil and Macrophage ability though their numbers may increase. Decreased NK number and ability to destroy virus infected cells. Decreased antibody response of T-helper cells. Especially affects children.
