Malnutrition

Question 1

Definition

Answer 1

State of nutrition where there is a deficiency, excess or imbalance of macronutrients (fat, protein, carbohydrates) and/or micronutrients (vitamins and minerals).
- This state results in adverse effects on body form, physical and cognitive functioning, and clinical outcome

Question 2

Malnourished NICE definition

Answer 2

• BMI under 18.5 kg/m 2
• Unintentional weight loss greater than 10% within past 3-6 months
• BMI under 20 kg/m 2 and unintentional weight loss greater than 5% within past 3-6 months

Question 3

Aetiology

Answer 3

• Inadequate intake of macronutrients and/or micronutrients: due to food poverty, chronic alcoholism, cognitive issues
• Impaired absorption: due to gastrointestinal disease
• Supra-normal nutritional demands : due to pregnancy, chronic inflammatory disease

Question 4

Protein-energy malnutrition (PEM)

Answer 4

A deficiency in macronutrients

Question 5

Types of PEM

Answer 5

• Kwashiorkor: Caused by inadequate protein intake despite normal energy (i.e. carbohydrate) intake. It is characterised by muscle atrophy, oedema, a distended abdomen and fatty liver disease
• Marasmus: Caused by a deficiency of all macronutrients. It is characterised by diffuse loss of muscle and fat tissue

Question 6

Common micronutrients in PEM

Answer 6

Vitamin A - Night blindness, immune deficiency
Iron - Anaemia, impaired cognitive development
Folate - Anaemia, glossitis, cognitive impairment
Iodine - Hypothyroidims, growth restriction, impaired cognitive development
Zinc - Delayed wound healing, impaired taste, hair loss, immune deficiency

Question 7

Epidemiology

Answer 7

• Age over 65
• Low socioeconomic status
• Institutionalisation :
  = recurrent hospital admissions,
  = living in a care home
  = sheltered accommodation
• Drug or alcohol abuse
• Chronic, progressive conditions :
  = cancer,
  = chronic lung disease
• Diseases causing malabsorption
• Diseases affecting dentition, sense of smell/taste, or swallowing
• Cognitive impairment :
  = Dementia
  = Learning difficulties
• Mental illness: depression, eating disorders

Question 8

Signs

Answer 8

• Low skeletal muscle mass
• Reduced/absent subcutaenous fat stores
• Abnormal obs: brady, hypotension, hypothermia
• Poor wound healing
• In children: stunting (low height for their age), wasting (low weight for their height), delayed sexual development

Question 9

Symptoms

Answer 9

• Unintentional, insidious weight loss
• Fatigue and lethargy
• Muscle weakness
• Poor concentration
• Cold intolerance
• In children: poor growth

Question 10

Diagnostic Criteria

Answer 10

The Malnutrition Universal Screening Tool (MUST) = identifies adults who are malnourished or at risk of malnourishment based on 3 factors:
- Body mass index (BMI)
- Amount of unplanned weight loss in past 3-6 months (as a % of body weight)
- Acute disease effect (i.e. if they are acutely unwell and are likely to have little/no nutritional intake for 5 days or more)

Question 11

Diagnosis

Answer 11

• Other anthropometric measurements:
  = height, weight, mid-upper arm circumference and triceps skin fold thickness
• Blood tests:
  = anaemia, electrolyte abnormalities (e.g. hypokalaemia, hypophosphataemia), hypoalbuminaemia, hypoglycaemia, low creatinine, specific micronutrient deficiencies
  = Investigations to determine the underlying cause of malnutrition: e.g. anti-tissue transglutaminase (TTG) antibodies and total IgA in suspected coeliac disease

Question 12

Management

Answer 12

• Treat the underlying cause
• Nutritional support:
  = A ‘food first approach’: 3 small meals a day with 2-3 snacks using high calorie ingreadients
• Oral nutritional support: high calorie, high protein supplements
• Enteral tube feeding
• Parenteral nutrition (IV)

Question 13

Complications of malnutrition

Answer 13

• Impaired immune function & increased susceptibility to infections
• Poor wound healing
• Impaired cognition
• Reduced quality of life
• Poorer health outcomes
• Death

Question 14

Complications of Tx

Answer 14

Refeeding syndrome: this is a constellation of potentially life-threatening electrolyte derangements that can arise with the re-introduction of nutrition in patients who are chronically malnourished.
serum
- hypophosphataemia,
- hypokalaemia
- hypomagnesaemia - and predisposes the patient to cardiac arrhythmias and seizures
At risk of developing if under 16kg/m2 or unintentional wt loss >10% within 3-6 months