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

Malnutrition is more common in which demographic?

Answer 2

Female; older age groups (>65)

Question 3

In which wards is malnutrition shown to have the highest prevalence?

Answer 3

Oncology and Care of the Elderly

Question 4

When considering diagnostic criteria, malnutrition is most prevalent in which disease group?

Answer 4

Gastrointestinal disease

Question 5

The 2014 BAPEN report identified what proportion of people to be admitted into hospital were malnourished at point of admission?

Answer 5

1 in 3

Question 6

Roughly what percentage of patients have lost weight at discharge according to the 2014 BAPEN report?

Answer 6

70%
(Mainly muscle mass)

Question 7

Causes of malnutrition in hospital

Answer 7

Reduced intake- Contraindicated, repeated NBM, disease associated anorexia, taste changes, food options, depression, fatigue, inactivity, oral health

Malabsorption/ maldigestion- function, length, losses, drug-nutrient interactions

Altered metabolism- A short ebb phase characterised by hypo-metabolism occurs immediately after injury and is characterised by a decrease in metabolic rate, oxygen consumption, body temperature, and enzymatic activity. The ebb phase is followed by a longer hypermetabolic flow phase marked by an increased catabolism, with a high oxygen consumption and an elevated REE rate.

Question 8

What are the negative impacts of malnutrition?

Answer 8

Physical and functional decline and poorer clinical outcomes

Increases- mortality, septic and post surgical complications, length of hospital stay, pressure sores, readmission and dependency

Decreases- wound healing, response to treatment, rehabilitation potential and QoL

Question 9

What is the cost of malnutrition in England per year?

Answer 9

£19.6 billion which is ~15% of the total public expenditure on health and social care.

Question 10

What is the process for diagnosing malnutrition?

Answer 10

Screen- A simple tool to identify risk. This is not assessment or diagnosis.

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

Diagnose- Nutrition diagnosis. (followed by the plan for the patient + goals)

Question 11

What tool is used to screen for malnutrition?

Answer 11

Malnutrition Universal Screening Tool (MUST)

Question 12

Malnutrition screening tool is required within how many hours of hospital admission?

Answer 12

Within 6 hours of hospital admission
Weekly thereafter

Question 13

What is the limitation of this screening tool?

Answer 13

It can miss malnourished populations especially where over-hydration, such as oedema/ ascites, is common or where specific screening for functional impairment is desired.

Question 14

If a patient is found to be malnourished after the screening process, who are they referred to? What does this person do?

Answer 14

Dietician
Assess nutritional and functional status

Question 15

List the components of a nutritional assessment.

Answer 15

Anthropometry, body composition, function, biochemical, clinical, dietary, social, physical, requirements

Question 16

What is anthropometry in a nutritional assessment.

Answer 16

Measurement of physical properties of the body–> BMI, mid-upper arm circumference, triceps skin-fold thickness, hand grip strength, multi-frequency bioelectrical impedance analysis, CT scan

Question 17

What is biochemistry in a nutritional assessment.

Answer 17

Tests used to estimate nutrient availability in fluid and tissue is critical for assessment in clinical nutrient deficiencies

Measurements of micronutrient and trace elements concentrations are time consuming and expensive, and therefore there needs to be a justified clinical need for requesting these

Many of these results are skewed as a result of the acute inflammatory response and therefore are not measured until CRP is below 10 micrograms per litre.

Question 18

What is clinical history in a nutritional assessment.

Answer 18

Medical histories can also prove useful, providing insight into nutrient related problems, alcohol and drug use, increased metabolic needs, increased nutritional losses. Chronic disease, recent major surgery or illness or surgery of the GI tract.

Question 19

What is dietary history in a nutritional assessment.

Answer 19

A diet history is perhaps the best means of obtaining dietary intake information and refers to a review of the individual’s usual patterns of food intake and the food selection variables that dictate the food intake.

Question 20

What comes under social+ physical in a nutritional assessment.

Answer 20

For example, information pertaining to socioeconomic status, the individual’s ability to purchase food independently, whether the person is living or eating alone, and physical or mental disabilities. Smoking or drug or alcohol addiction also.

Question 21

What comes under nutritional requirements in a nutritional assessment.

Answer 21

Indirect calorimetry

Question 22

What are the limitations of BMI?

Answer 22

At an individual level, BMI has several limitations due to the influence of factors such as gender, ethnicity and age being ignored.

BMI also cannot distinguish between fat mass and fat free mass, therefore BMI plays minimal significance in the dietetic assessment unless it is very low.

Question 23

What part of the nutritional assessment do the following images show?

Answer 23

Mid-upper arm circumference and tricep skin fold thickness

(Quick + easy bedside tests; can be used to calculate mid-arm muscle mass circumference and assessment of lean body mass - this is an important clinical outcome as improved lean body mass is associated with reduced length of hospital stay and improved functional ability.

Question 24

• What type of scan provides quantitative information on muscle composition and distribution?

Answer 24

CT scan

(Images from CT scans distinguish between visceral and subcutaneous fat and are considered highly accurate in evaluating levels of fat and fat free mass.)

Question 25

What are the negatives of using this type of scan?

Answer 25

Expensive and expose individuals to a small amount of radiation. Therefore, their use in detailing body composition tends to be restricted to research.

Question 26

What does the image below show and what is the purpose of this?

Answer 26

Hand-grip test

(This test reflects upper extremity muscle strength, which responds earlier to nutritional deprivation and repletion than other parameters such as muscle mass or body mass.)

Question 27

What is the main problem with bio-chemical tests as part of the nutritional assessment?

Answer 27

Measurements of micronutrient and trace elements concentrations are time consuming and expensive and therefore there needs to be a justified clinical need for requesting these.

Question 28

When what type of nutrition is used does biochemistry require intensive monitoring?

Answer 28

Parenteral nutrition

Question 29

What can a nutrition history reveal?

Answer 29

Anorexia, loss of sense or taste or smell, excessive alcohol intake, poor fitting dentures, chewing or swallowing problems.

Question 30

What is the most reliable method to measure energy expenditure and guide energy prescription?

Answer 30

Indirect calorimetry

Question 31

What is the most widely used form of indirect calorimetry?

Answer 31

Measurement of resting metabolic rate using a respirator gas exchange canopy

Question 32

What is used instead due to the inherent limitations of indirect calorimetry?

Answer 32

Predictive equations estimating resting metabolic rate are used in clinical practice to determine an estimated energy requirement.

Question 33

According to NICE, nutrition support should be considered in who?

Answer 33

People who are either:

• Malnourished
• At risk of malnutrition

Question 34

What criteria should a person meet to be malnourished

Answer 34

• BMI < 18.5 kg/m2
  or
• Unintentional weight loss >10 % past 3 - 6 / 12 (past 3-6 months)
  or
• BMI < 20 kg/m2 +unintentional weight loss > 5 % past 3 – 6 / 12

Question 35

What criteria should a person meet to be at risk of malnutrition?

Answer 35

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 36

What criteria should a person meet to be at risk of malnutrition?

Answer 36

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 37

What is artificial nutrition support?

Answer 37

The provision of enteral or parenteral nutrition to treat/ prevent malnutrition

Question 38

If nutrition support is indicated (screened and assessed by a dietitian) what is the first question that should be asked?

Answer 38

Is oral nutrition possible and safe?

Question 39

If oral nutrition is possible and safe what nutritional support is provided?

Answer 39

Dietetic counselling
Diet fortification
Oral nutritional supplements
Additional snacks

Question 40

If oral nutrition is possible and safe, but requires texture modification e.g. dysphagia, what should be considered?

Answer 40

Thickeners (thickens fluid to slow transit time through mouth and throat to facilitate a safer swallow) and additional support (oral, tube)

Question 41

In terms of oral nutritional support, what should you consider the need for if patient has a clinical condition that for example reduces sodium?

Answer 41

Modified diet

Question 42

If oral nutrition is not possible or safe, what is the next question that should be asked?

Answer 42

Is the GI tract functional and accessible?
If no- Parenteral nutrition
If yes-Enteral tube feeding

Question 43

Outline the whole Algorithm for the Treatment of Malnutrition using Artificial Nutritional Support

Answer 43

Question 44

What are the nutritional options available via the oral route

Answer 44

Fortification of meals and snacks
Altered meal patterns
Practical support
Oral nutritional supplements (ONS)
Tailored dietary counselling

Consider for any patient with inadequate food and fluid intakes to meet requirements, unless they cannot swallow safely, have inadequate gastrointestinal function or if no benefit is anticipated e.g. end of life care.

Question 45

Is enteral nutrition superior to parenteral nutrition? If so, why?

Answer 45

EN > PN

EN uses the gut

Question 46

What is the aim of PN?

Answer 46

To return to enteral → oral feeding as soon as clinically possible

Question 47

If gastric feeding is possible what is the approach to EN?

Answer 47

Naso-gastric tube (NGT) - feeding tube via the nose into the stomach.

Question 48

If gastric feeding isn’t possible what is the approach to EN?

Answer 48

Naso-duodenal tube (NDT)/ Naso-jejunal tube (NJT)

-

Question 49

Does a gastric outlet obstruction contraindicate NGT feeding?

Answer 49

Yes

Question 50

When a long term (>3 months) enteral tube feeding needs to be considered what is done?

Answer 50

Gastrostomy or jejunostomy - opening from the skin into either the stomach or jejunum

Question 51

The dietitian will determine the type of nutritional feed to put down the feeding tube. This is dependent on a number of factors including what?

Answer 51

Peptide
Renal factors
Immune factors
Low sodium
Elemental factors
Respiratory factors

Question 52

What needs to be done in order to determine the pH, after an NGT has been placed?

Answer 52

Aspiration

pH < 5.5 shows the NGT has been inserted in the right place

Question 53

If pH of the gastric contents is found to be greater than 5.5, what might this show and what must be done next?

Answer 53

May be due to misplaced NGT

CXR

Question 54

What are the complications associated with enteral feeding?

Answer 54

Mechanical: misplacement, blockage, buried bumper (NGT buried between gastric wall and skin)

Metabolic: hypergylcaemia, deranged electrolytes

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

Question 55

What is PN?

Answer 55

The delivery of nutrients, electrolytes and fluid directly into venous blood

Question 56

What are the indications for PN?

Answer 56

An inadequate or unsafe oral and/or enteral nutritional intake

OR

A non-functioning, inaccessible or perforated gastrointestinal tract

Question 57

What provides access for PN?

Answer 57

Central venous catheter (CVC) - either inserted in the subclavian, jugular or femoral veins with tip at the SVC and right atrium, or peripherally inserted central catheters with a tip still at the superior vena cava and right atrium.

Question 58

Are different CVCs used for short/long term use?

Answer 58

Yes

Question 59

What is the composition of PN?

Answer 59

Ready made/ bespoke “scratch” bags

Dietitian liaise with MDT → fluid and electrolyte targets

Question 60

What are the complications associated with parenteral nutrition?

Answer 60

Question 61

When do mechanical complication with parenteral nutrition typically occur?

Answer 61

When the line is inserted for use for parenteral nutrition.

Question 62

What does the CXR below show?

Answer 62

This CXR was performed following insertion of a right internal jugular central line (yellow arrow) and shows one of the potential complications of central line insertion – a large pneumothorax.The edge of the lung (‘pleural line’) is indicated by the red arrow.

Question 63

What is one of the main causes of bacteraemia and septicaemia in hospitalised patients?

Answer 63

Intravascular catheters

Question 64

Does Nutritions Support benefit the malnourished patient?

Answer 64

yes
An updated systematic review and meta-analysis included trials comparing oral and enteral nutrition support interventions, with usual care in non critically ill medical patients who were malnourished. The primary outcome was mortality. A total of 27 trials were included, of which five were published between 2015 and 2019. Patients receiving nutrition support compared with patients in the control group had significantly lower levels of mortality. A sensitivity analysis suggested a more pronounced reduction in the risk of mortality in recent trials, 2015 or later, compared with that in older studies, in patients with established malnutrition compared with that in patients at nutritional risk, and in trials with high protocol adherence compared with that in trials with a low protocol adherence. Nutritional support was also associated with a reduction in nonelective hospital readmissions, higher energy and protein intake, and weight increase. The review included a large trial known as the EFFORT trial (Effect of early nutritional support on Frailty, Functional Outcomes and Recovery of malnourished medical inpatients Trial). The study, published in The Lancet, is regarded as a well-designed, unblinded multicentre trial, aiming to test the hypothesis that providing patients at nutritional risk with individualised nutrition support would result in a better outcome than in those given the standard hospital diet without any further nutritional intervention. The investigators were able to show that in this intervention, it led to a significantly better outcome, including all-cause mortality, intensive care unit admission, non-elective hospital readmissions, major complications, and functional status at day 30.

Question 65

What is the most abundant circulating protein in healthy individuals

Answer 65

Albumin

Question 66

Where is albumin synthesised?

Answer 66

Liver (10-15g produced by hepatocytes every day).

Question 67

What is albumin synthesis stimulated by?

Answer 67

Hormone such as insulin, cortisol and growth hormone

Question 68

What is albumin synthesis inhibited by?

Answer 68

Pro-inflammatory substances including IL-6 and TNF.

Question 69

What type of molecules act on the liver to stimulate production of some proteins whilst down-regulating other e.g. albumin?

Answer 69

Cytokines

Question 70

What will a moderate inflammatory stimulus induce?

Answer 70

Plasma acute phase protein changes

Reduction in albumin which was previously most abundant protein in plasma

Question 71

Is albumin decreased or increased as part of the acute phase inflammatory response?

Answer 71

Decreased

Question 72

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

Answer 72

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 73

What is Refeeding syndrome?

Answer 73

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.

Question 74

Outline the pathogenesis of Refeeding Syndrome (RFS)

Answer 74

During starvation, the body aims to utilise energy stores, and there is a reduction in insulin secretion and an increase in glucagon secretion to produce glucose. Glycogen stores in the liver and amino acids in skeletal muscle are metabolised into glucose. Once these stores are depleted, which can be within 24 to 72 hours, metabolism shifts to derive energy from ketone production due to free fatty acids being released from fat stores, which are used instead of amino acids. This shift spares skeletal muscle breakdown and fat free mass is preserved to an extent. In addition, there is a decrease in BMR and the brain adapts to using ketone bodies instead of glucose, resulting in a loss of fat mass. In an effort to reduce energy expenditure, the action of cellular pumps is reduced, with electrolytes able to leak across the cell membrane. During starvation, there is an increase in extracellular water, total body water and sodium, and a depletion of total body potassium, magnesium and phosphate. Serum concentrations of these electrolytes are maintained whilst intracellular stores are depleted, sodium and fluid also leak into the cells, resulting in sodium and fluid intolerance.

Question 75

Outline the pathogenesis of Refeeding Syndrome (RFS) part 2

Answer 75

Micronutrient stores become depleted and thiamine deficiency is likely as it is water soluble and the body has limited stores. The introduction of carbohydrate results in the secretion of insulin, stimulating the sodium-potassium ATPase pump, requiring magnesium as a co-factor. This drives potassium into cells and sodium and fluid out of cells into the extracellular space. The carbohydrate and insulin secretion drives phosphate into cells as it’s required for energy storage as ATP. This results in an increased cellular uptake of glucose, potassium, magnesium and phosphate, and a subsequent reduction in extracellular concentrations. Thiamine is a coenzyme in carbohydrate metabolism and deficiency can occur on refeeding in a vitamin B depleted patient. These low concentrations of electrolytes and thiamine can then result in the clinical manifestations. In addition, carbohydrate reduces sodium and fluid excretion, causing an expansion of the extracellular fluid compartment, resulting in refeeding oedema and fluid overload.

Question 76

List the consequences of RFS

Answer 76

Arrhythmia, tachycardia, CHF → Cardiac arrest, sudden death

Respiratory depression

Encephalopathy, coma, seizures, rhabdomyolysis (breakdown of damaged muscle resulting in release of muscle cell contents into blood)

Wernicke’s encephalopy - confusion, ataxia, ocular abnormalities

Question 77

According to NICE, what are the criteria for defining the risk of RFS?

Answer 77

• 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 days

Question 78

Outline the management for RFS.

Answer 78

The dietician will give no more than 10 to 20 kcal per kilogram of nutrition, of that, 40 to 50% of the energy will be from carbohydrate (CHO)
Micronutrients will be given from the onset of feeding. Electrolytes need to be checked and replaced daily following trust policy

And Thiamine needs to be administered, the first dose of which needs to be given 30 minutes before onset of initial feeding

Fluid balance needs to be monitored to check for fluid shifts and to minimise the risk of fluid and sodium overload

Question 79

In Short Bowel Syndrome, if there is less than 100, 75 and 50cm of jejunum remaining respectively, what should be given?

Answer 79

< 100cm of jejunum = long term intravenous fluid + e

< 75 cm of jejunum = long term PN, fluid + e

< 50 cm of jejunum + colon = long term PN, fluid + e

Question 80

Short bowel syndrome patients lose large volumes of electrolyes (Na+) and what other substance, more than normal?

Answer 80

Water - abscence/less of colon

Question 81

After a jejunostomy (e.g. 6 weeks later), what is the stomal output target?

Answer 81

Less than 1.5L per day to prevent dehydration - you want patient to retain more water

Normal jejunostomy can initially put out 6L per day but this decreases with medication

Question 82

In patients with short bowel syndrome, would you limit or increase oral fluids?

Answer 82

Limit

Hypotonic oral fluids would pull sodium and water into the lumen which would increase stoma output

Instead, an electrolyte mix would utilise the sodium glucose coupled transport system operating mainly in the jejunum to promote sodium and water absorption from jejunum. This reduces stoma output and therefore dehydration

Question 83

What recommendations would you therefore give to such patients?

Answer 83

Less than 1L a day of:

Restrict hypotonic fluids - water, tea, coffee, squash, alcohol

Restrict hypertonic fluids - sorbitol and glucose

1L of glucose saline mix

Hyperphagic diet - patient consumes 2X energy and protein to compensate for lack of absorptive capacity

If no colon: high fat diet

Question 84

What urinary sodium value indicates dehydration?

Answer 84

<20 mmol/L