Malnutrition

Question 1

what is malnutrition

Answer 1

A state in which deficiency of nutrient such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function or clinical outcome
(A lack of nutrients/inappropriate nutrients linked to effect on body composition and function)
includes overnutrition

Question 2

what is an example of over nutrition

Answer 2

global obesity pandemic
obesity prevalence tripled between 1975 and 2016
Tenfold increase in childhood and adolescent obesity in four decades

Question 3

what is the prevalence of malnutrition globally

Answer 3

500 million affected
Eg Somalia – displaced persons camp
Disproportionately effects children

Question 4

what is the prevalence of malnutrition nationally

Answer 4

Mostly in care settings eg kids in hospital, hospital in and out patients, sheltered and elderly housing
Ageing population – increase chance of getting malnutrition

Question 5

how can chance of getting malnutrition vary

Answer 5

Risk changes with hospital ward – more likely on oncology, less likely on theatre or orthopaedic/trauma
Higher in certain disease – greater than 40% for GI disease and up to 80% for GI malignancy, high for oesophageal, gastric, pancreatic, colorectal

Question 6

how prevalent is malnutrition in surgical patients

Answer 6

Malnutrition high in those undergoing general surgery, GI, cancer surgery, far lower for major vascular surgery

Question 7

what is the mechanism of malnutrition

Answer 7

Impaired nutrient digestion and processing – malabsorption
Dysfunction of stomach, intestine, pancreas, liver
Excess losses by vomiting, NG tube drainage, diarrhoea, surgical drains, fistulae, stomas
Altered requirements
Increased metabolic demands – inflammation, cancer, wounds, burns, brain injury

Question 8

what is simple starvation (12-24 hours)

Answer 8

uncomplicated fasting
Mostly muscle breakdown for gluconeogenesis in the liver, glycogen stores for periphery and glucose for brain
fat used for liver (glycerol) and periphery

Question 9

what is simple starvation (7 days)

Answer 9

uncomplicated fasting
less muscle breakdown, ketogenesis over takes gluconeogenesis so ketone bodies for brain, peripheries
more fat broken down

Question 10

what is stress fasting

Answer 10

ischaemic tissue provides lactate for glycogen
muscle and fat for gluconeogenesis and small amount of ketogenesis
glucose for periphery and brain

Question 11

how are simple and stress starvation similar

Answer 11

insulin plasma and resistance increase

Question 12

how are simple and stress starvation different

Answer 12

simple dec metabolic rate, protein synthesis and blood glucose and stress inc them

Question 13

when does stress starvation increase a parameter more than simple starvation

Answer 13

muscle protein breakdown
gluconeogenesis
salt and water retention

Question 14

when does simple starvation increase a parameter more than stress starvation

Answer 14

plasma albumin
ketone bodies
nitrogen balance (dec less)

Question 15

what are the effects of malnutrition in healthy people

Answer 15

ventilation - loss of muscle and hypoxic responses
impaired liver function and fatty change
impaired gut integrity and immunity
decreased immunity and resistance to infection
impaired wound healing
reduced strength 
hypothermia
depression and apathy
reduced CO
impaired renal function

Question 16

what approximate weight loss is fatal

Answer 16

40%

Question 17

what does malnutrition result in

Answer 17

A major contribution increased morbidity and mortality, decrease function and quality of life, increased frequency and length of hospital stay and higher healthcare costs

Question 18

what is the cost of malnutrition

Answer 18

Attend GP more often, admitted to hospital more frequently, stay in hospital longer, succumb to infections, often discharged to long term care or die
4th biggest potential saving in the NHS (by identifying and treating it)
Malnutrition gets worse during hospital stay

Question 19

How does malnutrition get worse in hospital

Answer 19

Inadequate, unpalatable, unsuitable food
Cant reach food or feed themselves
Altered taste and poor appetite
NBM
Starved for investigations, can get cancelled or redone
Starved before and after surgery

Question 20

medical causes for inadequate intake

Answer 20

Poor diet
Poor appetite/anorexia/taste disturbances
NBM for investigation/medical reasons 
Pain/nausea
Dysphagia
Depression
Physical disability and inability to feed self
Unconsciousness

Question 21

environmental causes for inadequate intake

Answer 21

Inadequate quality (unpalatable, poor in nutrients, improper temperature)
Inadequate availability, outside reach of elderly or physically incapacitated patients
No protected meal times
Inadequate training and knowledge of staff

Question 22

how is inadequate intake prevented

Answer 22

Find at risk patients – screened (repeated weekly for inpatients or when there is clinical concern for outpatients)
Look out for – low weight, weight loss, poor intake or predicted to become poor, poor absorptive capacity, high nutrient losses, increased nutritional needs (eg burns, sepsis)

Question 23

what is the MUST screening tool

Answer 23

BMI, weight loss score, acute disease affect score
overall risk of malnutrition
management guidelines (in line with risk)

Question 24

how is malnutrition dealt with currently

Answer 24

Yearly screening
Educating staff
Protected meal times
Volunteers helping at meal times
Improving recording food and fluid intake
Dedicated nutrition support teams and dieticians

All Doctors should know about it and how to detect and treat it