Malnutrition Flashcards
Definition
Deficiency of nutrients including:
- Energy
- Vitamins
- Proteins
- Minerals
This causes measurable adverse on the body composition, function or clinical outcome
Prevalence of malnutrition in children.
Becoming an increase problem in the UK with being obese/ overweight:
- 28% of children 2-15 are overweight/ obese
- Obese children are increasingly staying obese in adulthood.
- 21% of 4&5 year olds are overweight/ obese
- 34% of 10&11 year olds are overweight/ obese.
Global perspective on malnutrition.
Despite increasing food availability, 500 mil people in the word still malnourished.
Types of severe malnutrition
Severely underweight:
- Marasmus
- Kwashiorkor
Marasmus
Type of severe malnutrition caused mainly by lack of energy (calorie intake).
Loss of subcutaneous fat and skeletal muscle.
Kwashiorkor
Type of severe malnutrition caused predominantly by protein malnutrition but sufficient calorie intake (energy).
Characterised by oedema- pitting oedema and distended abdomen.
Malnutrition in the UK
Affects over 3 million people, most commonly in hospitalised patients.
Most common population malnourished in the UK (top 3)
- Hospital inpatients- 30%
- Hospital outpatients- 20%
- Children in hospital/ sheltered and elderly at home - 14%
Types of malnutrition
Total deficiency:
Protein and energy malnutrition.
Nutrient deficiency:
Lack of specific nutrients such as vitamins, minerals, protein.
Malnutrition and GI/Liver disease.
Highly prevalent in diseases of the GI and liver.
- More than 50% patients with GI/Liver disease are malnourished.
- Up to 80% with GI malignancy are malnourished, esp. of the pancreas
Malnutrition and surgical patients.
Malnutrition can be very prevalent in surgical patients.
87% of patients undergoing general surgery become malnourished.
4 mechanisms of malnutrition.
- Inadequate intake of nutrients.
- Impaired digestion/ processing of nutrients- malabsorption.
- Excess loss of nutrients.
- Altered requirement of nutrients.
Malabsorption
Impaired digestion and processing of nutrients- can lead to malnutrition.
Caused by dysfunction of:
- Stomach
- Pancreas
- Liver
- Intestines
Causes of excess loss of nutrients [6]
XS loss= malnutrition.
Causes:
- Vomiting
- Nasogastric (NG) tube drainage.
- Diarrhoea
- Surgical drains
- Fistula
- Stomas (opening in the body)
Altered requirements [ 5 causes] + malnutrition
An increase in metabolic demand causes more energy required via calorie intake.
Insufficient calorie intake = malnutrition.
Causes: Inflammation Cancer Wounds Burns Brain injury
Starvation
The most extreme of malnutrition that leads to death- a severe deficiency pf calorie intake.
Type types:
Simple starvation
Stress starvation
Simple starvation
- what decreases [4]
- what stays the same [1]
- what increases [6]
Starvation only due to the lack of calorie intake. No other pathological conditions.
Decreases:
- Metabolic rate
- Protein synthesis
- Nitrogen balance
- Blood glucose
Increases:
- Muscle protein breakdown
- Ketone bodies (significantly)
- Gluconeogenesis
- Plasma insulin
- Insulin resistance.
- Salt and water retention
Stays the same:
Plasma albumin
What happens when we fast 12-24 hours.
- Liver
- Brain
- Fat
- Muscles.
The liver–> gluconeogenesis and glycogenolysis to release glucose.
Glucose released from the liver to the brain and periphery.
Fat –> broken down into fatty acids and glycerol and released to the liver and periphery.
Muscles –> break down to release amino acids to the liver.
What happens when we fast for long periods (2-3+ days)
- Liver
- Brain
- Fat
- Muscles.
Lipolysis–> More fat broken down into fatty acids and glycerol and released to periphery and liver.
Liver–> Ketogenesis and glyconeogenesis
- Ketogenesis releases ketone bodies to the brain and periphery.
- Gluconeogenesis releases glucose to the brain and periphery.
Less amino acids released from the break down of muscles.
Stress starvation
- what decreases [2]
- what increases [9]
Malnutrition caused by caesation of calorie intake with underlying an underlying pathology such as: trauma, sepsis and critical illness.
Increases:
- Metabolic rate
- Muscle protein breakdown (significantly)
- Protein synthesis
- Ketone bodies
- Gluconeogenesis
- Bood glucose
- Insulin plasma
- Insulin resistance (significantly)
- Salt and water retention (significantly)
Decreases:
- Plasma albumin
- Nitrogen balance
Differences between simple and stress starvation for:
- Metabolic rate
- Muscle protein breakdown
- Protein synthesis
- Metabolic rate: increases in stress, decreases in simple.
- Muscle protein breakdown is a lot greater in stressed starvation.
- Protein synthesis: increases in stress, decreases in simple.
Differences between simple and stress starvation for:
- Plasma albumin
- Nitrogen balance
- Ketone bodies
- Plasma albumin: decreases in stress, not affected in simple.
- Nitrogen balance decreases more in stress.
- More ketone bodies in simple.
Differences between simple and stress starvation for:
- Gluconeogenesis
- Blood glucose
- Insulin plasma concentration
Gluconeogenesis: increases more in stress.
Blood glucose: increases in stress, decreases in simple.
Insulin plasma increases the same in both
Differences between simple and stress starvation for:
- Insulin resistance
- Salt and water retention
Insulin resistance is the same in both.
Salt and water retention is significantly greater in stress.
Consequences of malnutrition on the body. [9]
Psychological- depression, apathy (self neglect= exacerbates condition).
Reduces cardiac output
Impaired renal function
Reduced physical strength
Hypothermia
Impaired wound healing
Impaired gut integrity and immunity
Loss of muscle for ventilation
Impaired liver function and fatty necrosis
Reasons for hospital causing malnutrition [4]
Food is inadequate/ unpalatable/ unsustainable
Patients cannot reach food or feed themselves
Patients have a poor appetite
Starved before and after surgery
Medical causes of inadequate intake [8]
Poor diet
Poor appetite/ taste disturbance
NBM for investigations or medical reasons
Pain/ nausea
Dysphagia- difficulty swallowing.
Depression
Physical disability
Unconsciousness
Environmental causes of inadequate intake
Poor food quality
Poor food availability
Meal times not protected
Inadequate training and knowledge of medical and nursing staff.
Patients at risk of malnutrition
Patients with:
- Low weight
- Weight loss
- Predicted/ poor intake of food
- Poor absorptive capacity
- High nutrient losses
- Increased nutritional needs, like sepsis, burns.
MUST screening tool.
Diagnostic tool used to predict the risk of a patient being malnourished.
Score 2 or more = high risk
- BMI score:
>20= 0
Normal, 18.5-20 = 1
<18.5 =2
+
- Weight loss score: unplanned weight loss in the past 3-6 months.
<5%= 0
5-10 =1
>10 = 2
+
- Acute disease effect score:
If patient is acutely ill and has been or likely to have not nutritional intake for >5 days, score= 2
MUAC
Mid upper arm circumference
A method of estimating the BMI category
Subject’s left arm is at 90 degrees and the distance between the acromion and olecranon process is measured.
Let the patient’s arm hang loose and measure the circumference of the arm midpoint of the distance.
MUAC< 23.5 = BMI< 20
MUAC >32 = BMI > 30
Action taken for someone at low risk of being malnourished.
Routine clinical care: Repeated screening
Hospital- weekly
Care home- monthly
Community- annually
Action taken for someone at medium risk of being malnourished.
Observation:
Document dietary intake for 3 days.
- Little concern = repeated screening
- Clinical concern= follow local policy and set goals to increase nutritional intake.
Action taken for someone at high risk of being malnourished.
Treatment:
Referral to dietitian, nutritional support team or implement local policy.
Set goals and improve overall nutritional intake
Monitor and improve care plan
