Malnutrition and nutritional assessment

Question 1

What is the definition of malnutrition?

Answer 1

A state in which deficiency, excess or imbalance, of energy, protein or other nutrients, results in a measurable adverse effect on body composition, function and clinical outcome

Question 2

What age is malnutrition more prevalent in?
What gender?
What ward?

Answer 2

Those aged 65 and over or younger than 18
Women
Orthopedic/trauma, surgery, medical

Question 3

What are the causes of malnutrition in the hospital

Answer 3

Reduced intake

Maldigestion, malabsorption

Altered metabolism

Question 4

What are reasons for reduced intake

Answer 4

Contraindicated
Disease related anorexia - pro inflammatory cytokines supressing hunger signals, reducing appetite
Taste changes
Nil by mouth
Food options
Depression
Inactivity
Oral health
Fatigue

Question 5

What are reasons for maldigestion and malabsorption

Answer 5

Function
Length
Losses - drains / stomas / vomiting / diarhea
Drug-nutrient interactions

Question 6

What are the reasons for altered metabolism

Answer 6

Ebb phase: drop in resting energy expenditure

Early flow phase: increase

Late flow phase: gradual decrease

Question 7

What is the physical and functional effect as well as effect on clinical outcomes with malnutrition

Answer 7

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 8

How to diagnose malnutrition

Answer 8

Screen
A simple tool to identify risk. This is not assessment or diagnosis - within 6 hours of hospital admission (MUST)
Limitations: Won’t trigger if they have asites or oedema

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

Anthropometry - external measurement of human body
Body composition - using CT
Function - muscle body strength
Biochemistry - inflammatory state , renal (potassium etc)
Clinical
Dietary
Social
Physical
Requirements - depending on energy and proteins

Diagnose
Nutrition diagnosis.

Question 9

What people should nutrition support be considered in?

Answer 9

1. Malnourished =

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.

2. At risk of malnutrition =

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 10

When should oral nutritional support be considered

Answer 10

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 11

What nutritional options are available via the oral route

Answer 11

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

Question 12

What is artificial nutritional support

Answer 12

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

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 13

How is the enteral route type decided?

Answer 13

Access:
Is gastric feeding possible?

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

Long term (> 3 months) = Gastrostomy / jejunostomy

Question 14

What is in the nutritional feeds

Answer 14

renal, low sodium, respiratory, immune, elemental, peptide.

Question 15

What is gastric outlet obstruction

Answer 15

NGT feeding contraindicated → NJT

Question 16

What are the complications associated with enteral feeding

Answer 16

Mechanical: misplacement, blockage, buried bumper

Metabolic: hypergylcaemia, deranged electrolytes

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

Question 17

How are misplaced NGTs found

Answer 17

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

Question 18

What is parenteral nutrition

Answer 18

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

Question 19

When would you use parenteral support

Answer 19

An inadequate or unsafe oral and/or enteral nutritional intake

OR

A non-functioning, inaccessible or perforated gastrointestinal tract

Question 20

What is parenteral support made of

Answer 20

Ready made / bespoke “scratch” bags.

MDT → fluid and electrolyte targets

Question 21

Where is the access point of parenteral support

Answer 21

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

Different CVCs for short / long term use.

Question 22

What are complications associated with parenteral nutrition

Answer 22

Mechanical:
Pneumothorax, haemothorax, thrombosis, cardiac arrhythmias, thrombus, catheter occlusion, thrombophlebitis, extravasion

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

Catheter related infections

Question 23

What is albumin?

Answer 23

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

Question 24

What is the acute phase response

Answer 24

Inflammatory stimulus → activation of monocytes & macrophages → release cytokines.
Cytokines act on liver to stimulate synthesis of some proteins e.g. c-reactive protein, whilst downregulating production of others e.g. albumin.

Question 25

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

Answer 25

No. Albumin synthesis ↓es in response to inflammation ∴ poor predictor of malnutrition during acute phase. However, do consider the aetiology / impact of the inflammatory response on nutrition status.

Question 26

What is refeeding syndrome

Answer 26

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 27

What are the consequences of RFS

Answer 27

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

Question 28

According to the National Institute for Health and Care Excellence (NICE), what are the criteria for defining the risk of RFS?

Answer 28

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 29

What does the management of RFS involve

Answer 29

Management

Start: 10 – 20kcal/kg
CHO 40 – 50% energy
Micronutrients from onset of feeding

Correct and monitor electrolytes daily following Trust policy

Administer thiamine from the onset of feeding following Trust policy

Monitor fluid shifts and minimise risk of fluid and Na+ overload