E10. Undernutrition Flashcards
what is undernutrition?
A state of nutrition in which a deficiency of energy, protein and other nutrients causes measurable adverse effects on tissue/body structure and function and clinical outcome
Groups at risk of undernutrition?
-Children- poor diet, growth
-Elderly- mobility, dentition, reduced appetite, poverty
-Disabled- mobility, swallowing
-Mental health- intake, Anorexia nervosa
-Disease eg infection/ GI disease, swallowing, cancer
Describe cancer induced Cachexia
Generally haematological cancers and breast cancers patients don’t suffer weight loss BUT Most solid tumours associated with weight loss eg upper GIT cancer, lung cancer
Classification of undernutrition?
use BMI on ONE NOTE
Describe the body’s adaptation to starvation
-Early starvation – liver glycogen used to provide energy
-Stores used up within 24 hours-
Glucose synthesised from protein
Fat metabolised to release FAs
-Long term- lipolysis is preferred, sparing protein
consequences of undernutrition on muscle function?
-Muscle wasting- (sarcopenia)
-Increased muscle fatigability
-Leads to deterioration in respiratory function
-Exacerbates pre-existing respiratory disease eg COPD
Consequences of undernutrition on cardiovascular function?
loss of cardiac muscle with reduced cardiac output, poor tissue perfusion, hypotension
Consequences of undernutrition on gastrointestinal tract
-Impaired gastric & pancreatic exocrine function- reduced digestion
-Mucosal cell atrophy- reduced absorption!
-Increased intestinal permeability to bacteria
Consequences of undernutrition on the immune system
-Impaired immune response, poor healing, increased sickness
-Reduced survival
eg Reduced survival in undernourished patients undergoing surgery
-Increased requirements for repair (NB injury factor)
-Longer hospital stays
-Post-operative complications more common in those who had lost more than 10% body weight
-Potentially increased risk of readmission
the effects of trauma?
-trauma increases the rate of weight loss- increased metabolic rate
-decreased muscle mass
-reduced visceral protein
-impaired immune response
-poor wound healing
-multiple organ failure
-death
ONE NOTE
Functional consequences of undernutrition?
-increased risk of hypothermia
-loss of subcutaneous fat
-thermoregulation is impaired- reduced thermogenic response to cooling
Psychological consequences of undernutrition
Progression through:
Fatigue/weakness
Deterioration in intellectual function
Lack of initiative
Bedridden
Apathy
Depression
Changes in behaviour & personality
Exhaustion
Treatment of undernutrition
Increase nutrient intake to reverse effects of undernutrition
- vitamins
- minerals
- macronutrients
- fluid
Describe energy expenditure from undernutrition
Not as much energy intake required because:
1) no thermic response to food
2) reduced cell mass
3) reduced energy expenditure per unit cell mass
4) lethargy/reduced activity
Thus, energy stores last longer
Describe re-introduction of nutrient needs
Re-introduction of nutrient needs to be done with care or refeeding syndrome
Describe refeeding syndrome
sudden administration of high glucose loads in undernourished patients can lead to:
-Hypokalaemia
-Hypophosphataemia
-Hyperglycaemia
-Respiratory failure (raised CO2 production)
-Cardiac failure
Initiate feeding carefully (slowly). Better to provide too little than too much initially
ONE NOTE FOR DIAGRAM
Describe treatment of patient with undernutrition
-Initial Intake- enough to prevent further weight loss- stabilisation
-Increase energy- positive energy balance- weight gain
Describe enteral feeding for treatment of patient with undernutrition
nasogastric tube for severe anorexia
initiated slowly to prevent refeeding syndrome eg 20kcal/kg/day or even 10kcal/kg/day if severe
Describe monitoring of treatment with undernutrition
electrolytes (phosphate, K+, Mg2+), fluid, glucose (refeeding)
ECG (cardiac arrythmias- refeeding)
Oedema- refeeding
Describe oral enteral feeding
-Supplementing food with household items- cream, cheese, milk powder (increase energy content)
-Supplementing food with modular products such as Maxijul/ Polycal (ACBS)- see BNF
-Oral liquid supplements- sip feeds
-complete feed or as adjunct to other route- ACBS
Describe enteral feeding through tube feeding (if unable to eat):
-Via nasal access:
Nasogastric
Nasojejunal (post‘pyloric’)
-Enterostomy feeding:
Percutaneous endoscopic gastrostomy (PEG/PG)
Jejunostomy
why is the enteral route more preferable?
-Stimulates gut-associated immune function
-Maintains intestinal mucosa- partly dependent on luminal nutrition
-Stimulates intestinal & biliary motility (helps prevent bacterial overgrowth & cholestasis)
-Cheaper & safer than parenteral nutrition
-If the Gut Works Use It! (golden rule)
Atrophy of gut may impair absorption, may need Parenteral Nutrition (intravenous):
Access:
- Peripheral
-Central (into superior vena cava)
-Complete feed made up under sterile conditions (Pharmacy)
-Contains lipid, CHO, protein, vitamins, minerals, trace elements
Typically:
2-3 litres volume
2000 kcal (50:50 CHO:FAT mix)
12 g nitrogen (as amino acids)
what should you avoid long term to prevent changes in the gut
-Severe inflammatory bowel disease
-Mucositis (inflammation of mucous membranes in mouth) following chemotherapy
-Severe acute pancreatitis
-Some patients with multi-organ failure
-Following major bowel surgery
nutritional and metabolic hazards of parenteral nutrition?
-Hyperglycaemia
-Electrolyte imbalance
-Micronutrient deficiencies
-GIT muscosal permeability
-Villous atrophy
catheter-related hazards of parenteral nutrition?
-Infection
-Occlusion
-Vein thrombosis
Hazards of parental nutrition- effect on other organ systems?
-liver disease
-biliary disease
