Malnutrition

Question 1

what is malnutrition?

Answer 1

lack of uptake or intake of nutrition = altered body compositions/ body cell mass - diminished physical + mental function from disease

Question 2

highest prevalence of malnutrition in what age groups?

Answer 2

highest in youngest (18-19) and oldest age groups (90+)

Question 3

How many people malnourished on admission ?

Answer 3

1/3 admitted to hospital malnourished on admission (big issue in the community_

Question 4

what factors exacerbate malnutrition in the hospital?

Answer 4

disease-related anorexia
inflexibility of mealtimes
quality of food
stress
gastro symptoms
lack of exercise
poly-pharmacy
low mood/ depression
co-morbidities - eg. dementia

Question 5

what is the impact of malnutrition on surgery?

Answer 5

postoperative mortality 10 times greater in those who lost more than 20% body weight after op

Question 6

evidence for link with malnutrition and poorer clinical outcomes

Answer 6

increased mortality, sepsis, post surgical outcomes, pressure sores

decreased wound healing, response to treatment

Question 7

how to screen malnutrition?

Answer 7

screening tool - low, medium, high risk

MUST tool

Question 8

how to assess malnutrition?

Answer 8

systematic process of collecting + interpreting info to determine nature/ cause of nutrient imbalance

Question 9

What is anthropometry?

Answer 9

anthropometry - science that defines physical measures of a person’s size, form, and functional capacities

eg. weight, arm circumference, hand grip strength, CT

Question 10

what is the biochemistry assessment?

Answer 10

intensive monitoring

identify the nutrient imbalances

Question 11

important of histories?

Answer 11

full medical history - meds/ past surgeries/ gastro symptoms etc
dietary history - allergies etc
social history - SES/ disabilities/ addiction

Question 12

How to measure nutrition requirements?

Answer 12

indirect calorimetry - resting metabolic rate

Avg. dietary intake that is needed for an individual

Question 13

When should nutrition support be considered?

Answer 13

malnourished

at risk of malnutrition

Question 14

when is a patient malnourished?

Answer 14

BMI less than 18.5
unintentional weight loss of more than 10% in past 3-6 months
BMI less than 20 + weight loss more than 5% in past 3-6 months

Question 15

when is a patient at risk of malnutrition?

Answer 15

Eaten or are likely to little/ nothing for more than 5 days

Poor absorptive capacity/ high nutrient losses/ increase nutritional needs

Question 16

what is artificial nutrition support?

Answer 16

provision of enteral/ parenteral nutrients to treat or prevent malnutrition

Question 17

when is parenteral feeding considered?

Answer 17

GI tract is not functional or accessible

Question 18

why is enteral feeding better than parenteral?

Answer 18

Given GI tract accessible - this is preferred as it uses the gut

Question 19

when do you use enteral or parenteral feeding?

Answer 19

when oral nutrition is not safe or possible

Question 20

what is a NGT?

Answer 20

naso-gastric tube - when gastric feeding is possible - enteral

Question 21

what is a NDT/ NJT?

Answer 21

naso-duodenal/ naso-jejunal - when gastric feeding is not possible - parenteral

Question 22

complications associated with enteral feeding?

Answer 22

mechanical: misplaced NGT - leads to death (aspirate needs to be extracted with acidic pH)
metabolic: hyperglycaemia/ deranged electrolytes

GI: aspiration/ laryngeal ulceration etc

Question 23

what is parenteral nutrition?

Answer 23

delivery of nutrients, electrolytes + fluid directly to venous blood

Question 24

when do you use parenteral nutrition?

Answer 24

inadequate/ unsafe oral or enteral nutritional intake

non-functioning or inaccessible GI tract

Question 25

Where is parenteral nutrition administered?

Answer 25

central venous catheter inserted at tip of superior venous cava

Question 26

complications associated with parenteral feeding?

Answer 26

mechanical: line inserted wrongly - leads to pneumothorax/ thrombosis/ haemothorax etc metabolic: deranged electrolytes, hyperglycaemia etc Catheter related infections

Question 27

Does nutritional support help?

Answer 27

patients receiving nutritional support have lower mortality rates/ reduction in readmissions

Question 28

what is albumin?

Answer 28

most abundant circulating protein in healthy individuals | - synthesised in liver

Question 29

what does low albumin indicate?

Answer 29

poor prognosis | albumin is low when inflammation is high

Question 30

effect of inflammation on albumin?

Answer 30

inflammation stimulus = release cytokines = cytokines act on liver and down-regulate production of albumin

Question 31

Is albumin a valid marker of malnutrition in the acute hospital setting?

Answer 31

No - albumin synthesis reduces in response to inflammation (can not be used as a marker)

Question 32

what is refeeding syndrome?

Answer 32

biochemical shifts + clinical symptoms that occur in malnourished/ starved on reintroduction of nutrition

Question 33

What happens during starvation?

Answer 33

``` Glycogenolysis Protein catabolism Ketone production Electrolyte depletion Decrease in basal metabolic rate - brain uses ketones instead of glucose ```

Question 34

What happens when nutrition is re-introduced to a starved individual?

Answer 34

Introduction of carbs = secretion of insulin = Na/K ATPase pump which requires magnesium as co-factor Mass cellular uptake of electrolytes Reduces sodium and fluid excretion = refeeding oedema hypokalaemia Thiamine deficiency

Question 35

What constitutes high risk of Refeeding Syndrome?

Answer 35

High risk - 1 or more of BMI less than 16/ low K+/Mg2+/PO4 prior to feeding/ no nutrition for more than 10 days/ unintentional weight loss of 15% or more for 3-6 months OR 2 or more of BMI less than 18.5/ past abuse of drugs or alcohol no nutrition for more than 5 days/ unintentional weight loss of 10% or more for 3-6 months

Question 36

What constitutes extremely high risk of Refeeding Syndrome?

Answer 36

BMI less than 14 | Negligible intake for more than 15 days

Question 37

Management of Refeeding Syndrome?

Answer 37

Start with only 10-20kcal per kg | Electrolytes/ fluids monitored