Malnutrition

Question 1

What are some consequences of malnutrition?

Answer 1

Impaired immune function
Delayed healing
Pressure sores
Immobility
Muscle weakness
Cardio-respiratory weakness
Pyschosocial effects
Length of stay
Hospital costs
Prolonged recovery

Question 2

What are causes of undernutrition?

Answer 2

Decreased intake
Increased requirements
Impaired absorption
Increased losses/utilisation

Question 3

What should be determined and recorded when assessing a malnutritioned patient?

Answer 3

Determine current nutritional status
Determine nutritional goals
Record baseline to facilitate monitoring.

Question 4

What should you be careful of when measuring weight and weight loss?

Answer 4

Be careful if oedema is present

Question 5

What percentage of weight loss is significant?

Answer 5

5-10 %

Question 6

What BMI signifies a) significant malnutrition, b) possible malnutrition and c) desirable BMI

Answer 6

a) <18.5
b) 18.5 - 20
c) 20-25

Question 7

Does a normal or high BMI exclude malnutrition?

Answer 7

No

Question 8

Why is BMI in the elderly inaccurate?

Answer 8

Because of height and muscle loss

Question 9

Why is albumin a poor marker of malnourishment?

Answer 9

It has a long half life.
It has a reduced concentration secondary to many things e.g. inflammation, sepsis, IV fluids, nephrotic syndrome and impaired liver synthesis

Question 10

What tool is used in Scotland for nutritional screening and is a standard of care?

Answer 10

MUST- malnutrition universal screening tool

Question 11

What factors make up a MUST score?

Answer 11

1. BMI >20 = 0
   18.5-20 = 1
   10% = 2
2. Acute disease effect
   Add a score of 2 is there has been or is likely to be no nutritional intake for >5 days

Question 12

What MUST scores are a) low risk, b) medium risk and c) high risk?
What actions should be taken for each category of risk?

Answer 12

a) 0 = low risk - normal care
b) 1= medium risk - observe and re-screen
c) 2 or more = high risk - nutritional support

Question 13

What measures are used to improve nutrition?

Answer 13

Food first
Oral supplements
Enteral Feeding
Parenteral feeding

Question 14

Describe various methods of enteral tube feeding.

Answer 14

Nasogastric
Nasojejunal
Percutaneous endoscopic gastrostomy
Percutaneous jejunostomy
Surgical jejunostomy

Question 15

What are contraindications of enteral feeding?

Answer 15

Lower GI Obstruction
Perforation
Active ulceration
Fistula
Facial injury
Severe diarrhoea or vomiting
Prolonged intestinal ileus
Intestinal ischaemia

Question 16

What are complications of enteral feeding?

Answer 16

Patient uncooperative
Malposition
Blockage
Diarrhoea
Aspiration
Metabolic disturbance

Question 17

What is parenteral feeding?

Answer 17

The administration of nutrient solutions via a central or peripheral vein

Question 18

What are negative features of parenteral feeding?

Answer 18

It is expensive
The complications are life-threatening
Needs specialist skills
Not physiological
Pyscho-social disturbance

Question 19

Define malnutrition

Answer 19

A state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse affects on tissue, body form, function and clinical outcome.

Question 20

What is the malnutrition cycle?

Answer 20

Illness–> hospital –> Anorexia and weight loss –> complications –> illness
This becomes a vicious cycle

Question 21

List some psychosocial causes of malnutrition

Answer 21

inappropriate food provision
Lack of assistance
Poor eating environment
Lack of cooking skills or facilities
Self neglect
Bereavement
Inability to access food
Deprivation
Loneliness

Question 22

List the biochemical markers commonly used to assess a patients nutritional status and describe their usefulness.

Answer 22

Albumin: A non-specific marker of illness
Transferrin: Synthesis reduced in protein restriction. Affected by APR, iron deficiency and liver disease.
Prealbumin: Reflects recent dietary intake rather than overall nutritional status. Increased in uraemia and dehydration. Decreased by APR, fasting. More useful in measuring response to nutritional support than initial assessment.
Retinol binding protein: Reflects recent dietary intake rather than overall nutritional status. Affected more by energy than protein restriction. Levels increased by increased glomerular filtration rate and alcoholism and decreased by chronic liver disorders and vitamin A and zinc deficiency.
Urinary creatinine: If renal function is normal, excretion rate mirrors muscle mass. Expressed per unit height. 24hr urine collection is required.
IGF1: Reduced in acute and chronic malnutrition and increases with repletion. Levels reduced in liver disease and renal failure.
Micronutrients: Poor correlation between plasma values and intracellular concentrion, especially during illness, therefore measurement of related coenzymes more useful. Usually can only be analysed by a specialised centre.

Question 23

List some indications for enteral feeding.

Answer 23

Inadequate or unsafe oral intake, and a functional, accessible GI tract (If the gut works, use it).
Unconscious patients
Neuromuscular swallowing disorder
Upper GI obstruction
GI dysfunction
Increased nutritional requirements.

Question 24

What are indications for parenteral feeding?

Answer 24

Should be considered in patients who are malnourished or at risk of malnutrition and meet either of the following criteria:
inadequate or unsafe oral and/or enteral nutritional intake
a non-functional, inaccessible, or perforated GI tract:
IBD with severe malabsorption
Radiation enteritis
Short bowel syndrome
Motility disorders

Question 25

What is refeeding synrome?

When can it arise?

Answer 25

Potentially fatal shifts in fluids and electrolytes and disturbances in organ function and metabolic regulation that may result from a rapid initiation of re feeding after a period of under nutrition.
It is less likely to occur with oral feeding as intake is usually limited by a poor appetite, but excessive feeding can be administered by EN or PN.

Question 26

What are some metabolic signs of refeeding syndrome?

Answer 26

Hypokalaemia
Hypomagnesaemia
Hypophosphataemia
Salt and water retention- fluid overload and oedema
Altered glucose metabolism

Question 27

What are some physiological features of refeeding syndrome?

Answer 27

Arrhythmias
Altered level of consciousness
Seizure
Respiratory failure
Cardiovascular collapse
Death

Question 28

How should patients who are at moderate risk of refeeding syndrome (i.e. have had more than 5 days of little or no nutrition) be managed?

Answer 28

Nutritional support should be introduced at a maximum of 50% of requirements for the first 48 hours.
Their clinical and biochemical parameters should be monitored.
If monitoring reveals no problem, increase nutrition support to meet full requirements.

Question 29

How should patients at high risk of refeeding syndrome be managed?

Answer 29

Check phosphate, magnesium, calcium and potassium.
Provide immediately before and during the first 10 days of feeding:
thiamine
vitamin B compound
multi-vitamin and mineral supplement
Start feeding at 5-10kcal/kg/day and slowly increase feeding over 4-7 days
Rehydrate carefully and supplement/correct levels phosphate, magnesium, potassium and calcium.
Monitor these levels for the first 2 weeks and amend supplementation as appropriate.