Malnutrition and Nutritional assessment

Question 1

Define Malnutrition

Answer 1

a state resulting from lack of uptake or intake of nutrition leading to altered body composition and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease”.

Question 2

Who is at risk of Malnutrition?

Answer 2

Older people, especially when admitted to hospital
Diabetes, CKD, Dementia, Cancer, Patients with any kind of GI dysfunction.
Every 1 in 3 people admitted to hospital has malnutrition. 70% of people have lost weight at discharge, mainly muscle mass.

Question 3

What is the impact of Malnutrition in the UK

Answer 3

Direct cause 66 hospital deaths

Contributory factor 285 hospital deaths£ 19.6 billion 15% of the total public expenditure on health and social care.

Question 4

What are the effects of Malnutrition?

Answer 4

Physical and functional decline and poorer clinical outcomes

↑ Mortality, septic and post surgical complications, length of hospital-stay, pressure sores, re-admissions, dependency

↓ Wound healing, response to treatment, rehabilitation potential, quality of life

Question 5

How is Malnutrition diagnosed?

Answer 5

MalnutritionUniversalScreeningTool MUST
Screen -

A simple tool to identify risk.
Carried out by any HCP.
This is not assessment or diagnosis

Assess- Dietician
A systematic process of collecting & interpreting information to determine the nature and cause of the nutrient imbalance.

Diagnose - Nutritional Diagnosis

Question 6

What is a major assessment tool in diagnosing Malnutrition?

Answer 6

Anthropometry
Measurement of bodies physical properties, different body compartments affected differently by malnutrition.
e.g. mid-arm muscle diameter, Multi-frequency bioelectrical impedance analysis, CTs provide information on fat and muscle contact. Muscle strength can predict mortality and morbidity better than muscle mass. Measurement of nutrient availability in fluid and tissue. Nutrition history may reveal many dietary issues.

Question 7

What are some limitations of using BMI?

Answer 7

Does not take into account gender, ethnicity, age. also cannot distinguish between fat mass and fat free mass.
Plays a small role in malnutrition diagnosis.

Question 8

How do you measure Indirect Calorimetry?

Answer 8

Most reliable methods to measure energy expenditure, measurement of resting metabolic rate using a respirator gas exchange canopy. In clinical practice, equations are used instead. Equations have their limitations as well. Will be used as a starting point

Question 9

Who should Nutritional support be considered in?

Answer 9

Malnourished

At risk of malnutrition

Question 10

Who is defined as Malnourished?

Answer 10

BMI < 18.5 kg/m2 or

Unintentional weight loss >10 % past 3 - 6 / 12 or

BMI < 20 kg/m2 + unintentional weight loss > 5 % past 3 – 6 / 12.

Question 11

Who is seen to be at risk of Malnutrition?

Answer 11

Have eaten little or nothing for > 5 days and / or are likely to eat little or nothing for the next 5 days or longer or

Have a poor absorptive capacity, and / or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism.

Question 12

What is Artificial Nutrition Support?

Answer 12

The provision of enteral or parenteral nutrients to treat or prevent malnutrition.

Question 13

What would the treatment be for someone in whom the oral route is possible & safe?

Answer 13

Oral nutritional support

Dietetic counselling, dietary fortification, oral nutritional supplements, additional snacks

Question 14

What would be the treatment be for someone with an accessible GI tract but in whom the oral route is not possible?

Answer 14

Enteral Feeding tube
Short term - 2-4 weeks - Fine bore naso-enteral tube
Long term - > 4 weeks - Long term tube placement

Continued monitoring required.

Question 15

What would be the treatment for someone with an inaccessible GI tract and in whom the oral route is not possible?

Answer 15

Parenteral Nutrition (but enteral support is better generally)

Question 16

What is the route for enteral support?

Answer 16

Enteral nutrition (EN) is superior to parenteral nutrition (PN).

Where parenteral nutrition is used, the aim is to return to enteral → oral feeding as soon as (where) clinically possible.

Question 17

How would the possibility of gastric feeding influence the type of tube used

Answer 17

Yes	=  Naso-gastric tube (NGT) 
No  	=  Naso-duodenal (NDT) / naso-jejunal tube (NJT)

Long term (> 3 months) = Gastrostomy/jejunstomy

Question 18

What are the complications associated with enteral feeding?

Answer 18

Mechanical: misplacement, blockage, buried bumper

Metabolic: hypergylcaemia, deranged electrolytes

GI: Aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea.

Question 19

What should the pH of NGT’s be?

Answer 19

Aspirate pH  5.5

If pH > 5.5 → chest x-ray, interpreted by trained professional following NPSA guidelines

Question 20

What is Parenteral Nutrition?

Answer 20

Parenteral nutrition (PN): The delivery of nutrients, electrolytes and fluid directly into venous blood.

Question 21

What are the indications of Parenteral feeding?

Answer 21

An inadequate or unsafe oral and/or enteral nutritional intake

OR

A non-functioning, inaccessible or perforated gastrointestinal tract

Question 22

What is the access of Parenteral nutrition?

Answer 22

Central venous catheter (CVC): tip at superior vena cava and right atrium.

Different CVCs for short / long term use.

Question 23

What is the Composition aspect of Parenteral nutrition?

Answer 23

Ready made / bespoke “scratch” bags.

MDT → fluid and electrolyte targets

Question 24

What are the complications of Parenteral nutrition?

Answer 24

Metabolic - Deranged electrolytes, hyperglycaemia, abnormal liver enzymes, oedema, hypertriglyceridaemia

Mechanical - Pneumothorax, Haemothorax, thrombosis, cardiac arrhythmias, thrombus, catheter occlusion, thrombophlebitis, extravasion

Catheter related infections

Question 25

What is the role of albumin in poor prognosis?

Answer 25

Albumin synthesised in the liver.
Low plasma albumin = poor prognosis.
A negative acute phase protein = ↓ plasma albumin when ↑ inflammation

Question 26

What happens to albumin in the acute inflammatory phase?

Answer 26

Inflammatory stimulus → activation of monocytes & macrophages → release cytokines.
Cytokines act on liver to stimulate production of some proteins whilst downregulating production of others e.g. albumin
A moderate inflammatory stimulus will induce plasma acute phase protein changes.
The negative acute phase protein, albumin, will↓.

Question 27

Is albumin a valid marker of malnutrition in the acute hospital setting?

Answer 27

No.
Albumin synthesis ↓es in response to inflammation ∴ it is not a valid marker of nutrition status nor an indication for nutrition intervention in the acute setting.
Best evidence = hypoalbuminaemia in obese trauma patients.
Dietitian focused on the aetiology/impact of the inflammatory state on nutrition status.

Question 28

What is Refeeding Syndrome?

Answer 28

A group of biochemical shifts & clinical symptoms that can occur in the malnourished or starved individual on the reintroduction of oral, enteral or parenteral nutrition.

Ketones, used for energy due to Free fatty acids being released from stores, decrease in basal metabolic rate resulting in fat mass loss.

Question 29

What are the consequences of Refeeding syndrome?

Answer 29

Arrhythmia, tachycardia, CHF → Cardiac arrest, sudden death
Respiratory depression
Encephalopathy, coma, seizures, rhabdomyolysis,
Wernicke’s encephalopy

Question 30

What do low Carbohydrate concentrations lead to?

Answer 30

Secretion of insulin stimulating NaKAtpase pump requiring Mg as a co-factor driving K into cells and Na +fluid out, carbohydrate and insulin secretion drives K into cells as it’s required for ATP. Results in increased cellular uptake of glucose, K, Mg, Phosphate + reduction in extracellular concentrations

Question 31

What are some effects of Refeeding syndrome?

Answer 31

Hypokalaemia
Hypomagnesaemia
Hypophosphataemia
Thiamine deficiency
Salt + water retention - oedema

Question 32

What are the criteria for defining the risk of Refeeding syndrome?

Answer 32

At risk:
Very little or no food intake for > 5 days

High risk: 
 1 of the following:
BMI < 16 kg/m2
Unintentional weight loss > 15 % 3 – 6 /12
Very little / no nutrition > 10 days
Low K+, Mg2+, PO4 prior to feeding

Or  2 of the following:
BMI < 18.5 kg/m2
Unintentional weight loss > 10 % 3 – 6 / 12
Very little / no nutrition > 5 days
PMHx alcohol abuse or drugs (insulin, chemotherapy, antacids, diuretics)

Extremely high risk:
BMI < 14 kg/m2
Negligible intake > 15 day

Question 33

What is the management of Refeeding syndrome?

Answer 33

Start 10-20 kCal/kg CHO 40-50% energy
Micronutrients from onset of feeding

Correct & Monitor electrolytes daily following Trust Policy

Administer thiamine from the onset of feeding following trust policy.

Monitor fluid shifts & minimize risk of fluid & Na+ overload.