Malnutrition

Question 1

What is the definition of malnutrition?

Answer 1

Malnutrition refers to a sudden or chronic decrease in the intake of sufficient nutrition to support the body’s requirements for growth, healing, and maintenance of life. Malnutrition can be acute or chronic

Question 2

What is acute malnutrition?

Answer 2

a brief period of inadequate nutrition that is most commonly in relation to an acute illness with a high inflammatory state, such as pneumonia, and results in muscle wasting and rapid weight loss.

Question 3

What is chronic malnutrition?

Answer 3

inadequate nutrition that lasts longer than three months. Often secondary to social, behavioural, and economic factors in addition to illness-related causes.

Question 4

What are some standardised screening tools for Malnutrition?

Answer 4

Malnutrition Universal Screening Tool (MUST), the Malnutrition Screening Tool (MST) and Mini-Nutrition Assessment (MNA).4

Question 5

Aetiology of malnutrition

Answer 5

Normally, as metabolic demands increase due to illness, injury or stressors such as exercise, people are able to adapt their nutritional intake to meet their body’s requirements.

In settings of chronic disease and certain drugs, this can become extremely difficult and lead to acute or chronic malnutrition.

Question 6

What are the 3 main reasons why someone might be malnourished?

Answer 6

Inadequate amounts of nutrients (e.g. poor variety in diet)
Difficulty absorbing nutrients (e.g. gastrointestinal dysfunction such as coeliac disease)
Increased nutritional demands (e.g. post-surgery for healing)

Question 7

RFs for malnutrition

Answer 7

• Chronic illness
• Elderly
• Supported accommodation
• Alcohol
• Being hospitalised for extended periods of time
• Problems with dentition, taste or smell
• Polypharmacy
• Social isolation and loneliness
• Mental health issues including grief, anxiety and depression
• Cognitive issues including confusion

Question 8

Clinical features of malnutrition

Answer 8

• High susceptibility or long durations of infections
• Slow or poor wound healing
• Altered vital signs including bradycardia, hypotension, and hypothermia
• Depleted subcutaneous fat stores
• Low skeletal muscle mass

Question 9

Children and malnutrition

Answer 9

Wasting: low weight for height
Stunting: low height for age
Underweight: low weight for age

Question 10

Albumin and malnutrition

Answer 10

Hypoalbuminaemia occurs in conditions where:
- there is an excessive amount of protein being lost (e.g. protein-losing enteropathy, chronic renal disease)
- where the production of albumin is impaired (e.g. liver disease due to loss of synthetic function or malnutrition due to a paucity of protein).
- Hypoalbuminaemia can also develop in the context of inflammatory states such as infections.
- As a result, serum albumin should not be relied on in isolation to assess a patient’s nutritional state as there are a wide variety of factors which influence levels.

Question 11

History when checking malnutrition

Answer 11

Weight history: including current weight, recent changes to weight and changes to fit of clothes
Meal history: regularity of meals including skipping meals
Protein intake: intake of high-quality protein
Hydration: intake of fluids

Question 12

Clinical examination

Answer 12

• Weight: unexpected weight loss from someone’s normal weight is indicative of a period of malnutrition. This includes people who are clinically overweight and obese.
• Body mass index (BMI): a patient’s BMI indicates whether they might be malnourished. It is not however as accurate as history and clinical examination, and should never be used in isolation.
• Review of muscle mass stores
• Review of subcutaneous fat stores
• Consideration could also be given to measuring a patient’s grip strength, triceps skin fold thickness and mid-arm muscle circumference.5

Question 13

Management of malnutrition

Answer 13

Malnutrition should be treated like any other medical condition with consideration of the patient’s goals of care, prognosis, and other social factors. Dietitians should be involved in leading the management of patients with malnutrition.

If a specific reversible cause of malnutrition is identified (e.g. infection or inflammatory state), this should be treated as soon as possible.

Question 14

When should oral nutrition be used?

Answer 14

should be used as long as it is possible, with the use of oral nutritional support such as high-energy-high-protein supplements and fortified food products. Often, minor changes to diet will have a significant positive impact on a patient’s nutritional status.

Question 15

What happens if a patient is unable to safely swallow?

Answer 15

nasogastric feeding should be considered. For long-term feeding, a gastrostomy (PEG or RIG) or jejunostomy should be considered.

Question 16

When should parenteral nutrition be used?

Answer 16

reserved for patients with intestinal failure or inaccessible digestive tracts.

Question 17

What is and what happens in refeeding syndrome?

Answer 17

Refeeding syndrome is a condition caused by a rapid re-introduction of normal nutrition in patients who are chronically malnourished.

In the context of chronic malnutrition, a patient’s intracellular stores of key electrolytes such as potassium and phosphate become depleted.

Question 18

What happens when in refeeding syndrome the patient is suddenly provided with normal levels of nutrition

Answer 18

there is a sudden shift of these electrolytes from the extracellular to the intracellular compartment driven by a large insulin response and other factors. This can ultimately lead to a sudden drop in extracellular levels of key electrolytes resulting in hypokalaemia and hypophosphataemia. This can subsequently lead to cardiac complications (e.g. arrhythmias) and seizures.

Question 19

How do we prevent refeeding syndrome

Answer 19

To prevent refeeding syndrome, nutrition is re-introduced more gradually under the guidance of a dietician and the patient’s electrolytes are monitored closely, allowing deficiencies to be identified early and replaced appropriately.

Question 20

What are the complications of malnutrition?

Answer 20

Impaired immunity (increased risk of infections)
Poor wound healing
Growth restriction in children
Unintentional weight loss, specifically the loss of muscle mass
Multi-organ failure
Death

Question 21

Key points of malnutrition

Answer 21

Malnutrition refers to a sudden or chronic decrease in the intake of sufficient nutrition to support the body’s requirements for growth, healing, and maintenance of life. It can be acute or chronic.
Validated screening tools for malnutrition include MUST, MST and MNA.
Major risk factors include chronic illness, increasing age, living in supported accommodation and alcohol abuse.
A comprehensive nutrition-focused history and exam are required to assess the cause and severity of the malnutrition and determine an appropriate management plan.
When treating malnutrition, it is important to always consider oral methods of nutritional support first before opting for parenteral routes.
Complications of malnutrition include increased risk of infections, poor wound healing, growth restriction (in children), loss of muscle mass and organ failure/death.