Lecture 5: Malnutrition & Cachexia Flashcards
What is malnutrition?
The general state of inadequate nutrient and/or energy intake and absorption to meet metabolic demands.
What are the 3 main causes of malnutrition?
Poor intake
Poor absorption
Increased metabolic needs.
How much of US adults do not consume adequate amounts of nutrients on a regular basis?
85%!
How many households in the US were considered low or very low in terms of food security?
10%
What tools can we use to screen for malnutrition?
Subjective Global Assessment (SGA)
Malnutrition Universal Screening Tool (MUST)
Malnutrition Screening Tool (MST)
What is the SGA?
Combines hs, ROS, and PE findings.
It is mainly to categorize pts by their nourishment status.
What is the MUST?
Utilizes BMI, unintentional weight loss, and effect sof acute disease to measure RISK OF MALNUTRITION.
Offers recommendations.
What is the MST?
2-question screen, also helps determine RISK OF MALNUTRITION.
How do we check nutritional status in adults vs children?
Adults: generally weight
Children: Body length and head circumference.
What specific organs would show nutrient malnutrition and how?
Integumentary: skin, hair, nails, mucosal membranes.
Hematopoiesis: immunosuppression, anemia, bleeding or bruising.
Neurologic: Paresthesia, weakness, cognitive delay or impairment.
Where do we measure skinfold thickness? How?
Triceps
Using calipers
What skinfold thickness are men usually at? Women?
Men: 12.5-20mm
Women: 16.5-25mm
What midarm muscle circumference % is suggestive of malnutrition?
< 15th percentile.
Measured with a tape measure.
What is underweight for adults?
BMI <18.5
What is underweight for children?
Depends on growth charts.
What is the difference between stunting and wasting?
Stunting has to do with low HEIGHT for age.
Wasting has to do with low WEIGHT for age.
Note:
Stunted trees are SHORT.
Is an underweight patient malnourished?
Not always!
What is the gold standard to screen for malnutrition?
DEXA scan (Dual-energy XRAY absorptiometry)
What proteins do we measure for malnutrition?
Somatic and visceral proteins.
How do we assess somatic proteins?
24 hour urinary creatinine excretion.
This assesses the relative state of skeletal muscle mass.
What are the visceral proteins?
Albumin, transferrin, prealbumin, and retinol-binding protein.
Which visceral protein do we commonly measure? Why?
Albumin. It has the longest half-life at 20 days.
However, it can be decreased in any septic state
Normal range is about 3.5-5.5
When do we measure prealbumin?
Acute malnourishment (t1/2 is 2d)
Depressed in acute stress states as well.
When do we measure transferrin?
Iron deficiency elevates it.
T1/2 is 8-10d
What is dietary reference intake?
Nutrient reference values developed by the institute of medicine to quantify recommended levels of a given nutrient necessary for optimal health based on a patient’s individual characteristics.
Includes:
RDA
AI
EAR
EER
UL
What are all the things included in a DRI?
RDA: Recommended dietary allowance
AI: Adequate intake
EAR: Estimated Average Requirement
EER: Estimated Energy Requirement
UL: Tolerable upper level intake
What is RDA/recommended dietary allowance?
The average amount of nutrient sufficient to meet the requirements of 97-98% of health individuals.
What is AI/adequate intake?
Recommended average daily intake level based on health individuals.
Used when RDA cannot be determined!!
What is EAR/estimated average requirement?
Average nutrient level needed to meet 50% of individuals.
Often known as the threshold/minimum.
What is EER/estimated energy requirement?
Average dietary intake predicted to maintain energy balance.
It includes extra needs such as pregnancy, lactation, or childhood.
It is only the minimum, no upper level.
What is UL/tolerable upper intake level?
Highest average daily nutrient intake level that won’t cause adverse effects.
AKA the most you can consume in nutrients without consequences.
What is BMR and how do we determine it?
Basal Metabolic Rate
Energy spent to maintain basic metabolic processes.
Determined by subject reclining after a 12 hour fast.
What is Basal energy expenditure/BEE?
BMR extrapolated to 24 hours.
What is RMR and how do we determine it?
Resting Metabolic Rate
Includes BMR + recent eating or exercise.
10-20% higher than BMR on avg.
What is Resting energy expenditure/REE?
RMR extrapolated to 24 hours.
What equation is used to estimate energy requirements for an individual?
Harris-benedict equation
What information does the Harris-Benedict Equation need?
Weight in kg
Height in cm
Age
How is EER calculated from BMR?
BMR is multipled to adjust for a person’s physical activity level.
What equation is the most current one to calculate EER now?
Institute of Medicine equation.
What is the most common nutrition deficiency in the world?
Iron Deficiency.
What are two common nutrient deficiencies in underdeveloped countries?
Vitamin A
Iodine deficiency
What is marasmus?
A state of BOTH protein and total energy malnutrition.
Results in massive wasting and weight loss.
How does someone with maramus appear?
Relatively large head with large, staring eyes.
Emaciated, weak appearance.
Thin skin and hair that is easily plucked.
Bradycardia, hypotensive, hypothermic
Like gollum
What is kwashiorkor?
A state of PROTEIN malnutrition with normal caloric intake.
What demographic often presents with kawshiorkor?
Babies weaned from the breast in low-income countries.
What are some PE findings in someone with kwashiorkor?
Growth retardation
Distended abdomen with dilated intestinal loops.
Classic edematous appearance with pitting edema.
Why does kwashiorkor present with pitting edema?
Hypoalbumenia leads to low osmotic colloid pressure.
Lack of protein = lower production of albumin.
What is cachexia?
Multifactorial wasting syndrome with continuous loss of skeletal muscle mass, with or w/o loss of fat.
What is significant about cachexia?
Not fully reversible by nutritional support.
Progressive functional impairment.
What kind of pts are most commonly cachetic?
50-80% of cancer patients.
Accounts for up to 20% of cancer mortality.
Also appears in pts with AIDS.
What is the suspected cause of cachexia?
Mitochondrial dysfunction.
Leading to…
Decreased ATP and protein synthesis
Increased oxidative stress in the body
Elevated inflammatory markers
What are the two general ways we can provide nutrients to a patient?
Enteral
Parenteral
What are the enteral nutritional options?
Oral and feeding tubes:
Nasogastric/NG tubes for short-term.
Percutaneous endoscopic gastrostomy tube/PEG for long-term feeding.
Jejunal tubes as well for high aspiration risk patients.
What are the parenteral nutritional options?
Central line delivery
TPN: Total parenteral nutrition
PPN: Partial parenteral nutrition.
PPN is only used in situations where the gut is not working properly.
What are the concerns with parenteral nutrition treatment?
Higher risks of bacteremia and sepsis, poor weight gain.
Fat overload syndrome: fever, HSM, and coagulopathy
Bone metabolism disease in children with long-term use.
What is fat overload syndrome specifically a complication of?
Intravenous lipid emulsion therapy (ILE)
What are the general treatment principles for an anorexic patient?
Frequent spacing of small meals.
Prioritize energy-dense foods.
Powdered/liquid supplementation
Adding calories/nutrients to preferred foods.
What is dumping syndrome?
Sweating, flushing, dizziness, and tachycardia caused by large amounts of food moving rapidly from the stomach to the bowel.
When is dumping syndrome commonly seen? What do we do to treat it?
Tube feeding and post-gastric surgery.
Slowing infusion rate and amount of feeding given at one time.
What is megestrol acetate/megace? Indications?
A synthetic progestin used as an appetite stimulant.
Indicated for:
Anorexia or cachexia associated with AIDS.
Off-label: Cancer-related cachexia
What are the SEs and CI of megace?
SE: GI upset, HA, insomnia, rash
CI: Allergy
What is cyproheptadine/periactin?
1st gen antihistamine used as appetite stimulant.
Can be given to adults or peds.
What are the SEs and CIs of periactin?
SE: dizziness, drowsiness, anticholinergic.
CIs: Allergy, MAOI use, gastric or urinary obstructions, acute angle-closure glaucoma, and gastric ulcer.
NOT FOR USE IN:
preemies
neonates
Pregnant or breastfeeding
elderly or debilitated
What is dronabinol/marinol? Indications?
Cannabinoid-derived agent (THC).
Schedule 3 drug.
Indicated for anorexia/cachexia associated with AIDS
What are the SEs and CIs of marinol?
SE: euphoria, GI upset, dizziness, drowsiness, AMS
CI: allergy, use of disulfiram or metronidazole in past 2 weeks, allergy to alcohol or SESAME OIL
