Malnutrition and nutrition intervention

Question 1

Define malnutrition

Answer 1

State of deficiency or excess (imbalance) of energy/protein/nutrients resulting in adverse effects on body composition and function

Question 2

Groups most at risk of malnutrition

Answer 2

> 65yrs
Gastrointestinal dysfunction
Chronic disease e.g. DM
Progressive disease e.g. cancer
substance abuse

Question 3

Causes of hospital malnutrition

Answer 3

• Reduced intake e.g. due to anorexia, Nil by mouth, inactivity, depression
• maldigestion/malabsorption
• altered metabolism (may be in the catabolic phase of their condition)

Question 4

What is the impact of malnutrition

Answer 4

Increased: mortality, sepsis, complications
Decreased: wound healing, rehab, QOL

Question 5

How would you diagnose malnutrition?

Answer 5

1. Screen tool (with weight loss and height)
2. Dietitian assesses with examinations (det. nature and cause of nutrient imbalance)
3. Diagnosis

Question 6

What are the examinations involved in diagnosing malnutrition?

Answer 6

Anthropometry - body measurements e.g. height
body composition - fat distribution
function - using hand grip
biochemistry - check K+ and other electrolytes
Clinical - PMH, surgical history etc
Dietary - eating habits
Social - socioeconomics, isolation
Physical - hair, teeth, nails
Nutritional rq using calorimetry

Question 7

Who should nutritional support be considered for?

Answer 7

Low BMI (<18.5) or Weight Loss (>10% in 6 months)
Those at risk (not eaten in 5 days/poor absorption/high nutrient losses/increased rq due to catabolism)

Question 8

What are the different types of nutritional support?

Answer 8

Oral
Enteral tube feeding
Parenteral tube feeding

Question 9

What is the order of preferential options nutritional support?

Answer 9

Oral - Enteral - Parenteral

Question 10

What is oral nutritional support?

Answer 10

Dietetic counselling,
fortification,
oral supplements,

Question 11

Who is oral nutritional support geared towards

Answer 11

Inadequate food and fluid intake
unless they cannot swallow/have GI issues

Question 12

If oral nutritional support is inadequate, what is the next step?

Answer 12

Enteral Tube feeding

Question 13

How does enteral tube feeding work

Answer 13

Bypass the mouth, feed the stomach/duodenum/jejunum

Question 14

What are the different access points for enteral nutrition?

Answer 14

If Gastric Feeding Possible - nasogastric tube
If not: naso-duodenal or naso-jejunal

Question 15

What are the options for longer term enteral nutrition?

Answer 15

> 3months: gastrostomy or jejunostomy

Question 16

What is a contraindication for the nasogastric tube and what is the alternative?

Answer 16

Gastric outlet obstruction
Naso-jejunal tube

Question 17

What are the complications associated with enteral feeding?

Answer 17

Mechanical (blockage, misplacement)
Metabolic (hyperglycaemia, deranged electrolytes)
GI (aspiration, ulceration, D&V)

Question 18

What is parenteral nutrition

Answer 18

Delivery of nutrients, electrolytes and fluids directly into venous blood

Question 19

When would you choose parenteral nutrition?

Answer 19

1. Enteral not adequate
2. Limited tube feeding not possible
3. GI tract not functional or accessible

Question 20

Where is the access for parenteral nutritional support?

Answer 20

Directly into venous bloods - central venous catheter at tip of SVC or others

Question 21

What are the complications associated with parenteral feeding?

Answer 21

Mechanical (pneumothorax, thrombosis, arrythmias)
Metabolic (deranged electrolytes, abnormal liver enzymes, hyperglycaemia)
Catheter-related infections

Question 22

Is albumin a good marker of malnutrition in an acute hospital setting?

Answer 22

No - low albumin levels in inflammation as it is a negative acute phase protein

Question 23

What is the acute phase response?

Answer 23

Inflammatory stimulus releases cytokines Cytokines stimulate the synthesis of some proteins (CRP) / downregulate others (e.g. albumin) in liver

Question 24

What is RFS?

Answer 24

Refeeding Syndrome - clinical symptoms occurring in malnourished individuals on the reintroduction of oral/enteral/parenteral nutrition

Question 25

Explain the pathophysiology of RFS

Answer 25

Starvation - decreased insulin secretion, use of protein/fat stores in body and salt/water intolerance. Cells will give up intracellular ions (K+, Mg+) to account for low extracellular levels.

Once nutrition restarted + insulin secretion is upregulated, ions will move back into cells causing hypokalaemia, hypomagnesaemia, thiamine deficiency

Question 26

What are the clinical symptoms of RFS?

Answer 26

Cardio - arrythmias, tachy, CA
Neuro - encephalopathy, coma, seizures, wernicke’s encephalopathy
Resp - respiratory depression

Question 27

Who is at risk for RFS according to NICE?

Answer 27

Little or no food intake for > 5 days

Question 28

Who is at high risk for RFS according to NICE?

Answer 28

BMI < 16, weight loss >15% in 6 months, little nutrition

Question 29

What is the management for RFS?

Answer 29

1. Administer thiamine 30mins b4 feeding (to avoid encephalopathy)
2. Monitor electrolytes daily
3. Diet - 10/20kcal per kg, micronutrients
4. Monitor fluid shifts and minimise hypernatraemia