Malnutrition in disease and ageing

Question 1

How can malnutrition be defined?

Answer 1

A state resulting from lack of uptake or intake of nutrition leading to altered body composition (decreased fat free
mass (FFM) and body cell mass (BCM)) leading to diminished physical and mental function and impaired clinical outcome
from disease.

Question 2

What is malnutrition associated with in regard to clinical outcomes?

Answer 2

• Increased mortality
• Decreased muscle strength
• Decreased wound healing
• Increased (infectious) complications
• Increased length of hospitalization
• Decreased functioning
• Decreased quality of life

Question 3

Think of symptoms and effects of illnesses and treatments that can lead to the following:
* reduced food intake
* impaired digestion and absorption
* altered nutrient metabolism and excretion

Answer 3

Reduced food intake:
* Symptoms and effects of illness: anorexia due to illness (e.g. pain with eating, difficulty chewing, depression, etc.)
* Treatments: surgery, restrictive diets, side-effects medication
Impaired digestion and absorption:
* Symptoms and effects of illness: inflammation associated with bowel conditions, altered structure or function of mucosa.
* Treatments: radiation therapy, surgeries, side effects of medication
Altered nutrient metabolism and excretion:
* Symptoms and effects of illness: elevated metabolic rate, nutrient losses due to excessive bleeding, diarrhea, etc.
* Treatments: chemotherapy, use of diaretics, side effect of medications, etc.

Question 4

What are two main indicators of malnutrition?

Answer 4

• Low BMI
• Uninentional weight loss

Question 5

What diagnostic criteria does a patient need to meet in order to be malnourished (GLIM criteria)?

Answer 5

• Weight loss or low BMI or low muscle mass (phenotype criterion)
  AND
• Assimillation loss or lower food intake or inflammatory disease (etiology criterion)

Question 5

Where can you find most malnourished persons?

Answer 5

• Primary care and home care
• Hospital
• Nursing homes

Question 6

Name three hospital departments that have the highest rate of severe malnourished patients.

Answer 6

Oral maxillofacial surgery, oncology, gastrointestinal.

Question 7

When comparing studies on malnourishment in patients, what should you pay attention to?

Answer 7

To which definition/screeningtool was used to determine (risk of) malnutrition.

Question 8

Before a patient can be termed as malnourished, the patient has to be screened. For this, there are 4 phases. Name and describe these phases.

Answer 8

1. Risk screening
2. Diagnositc assessment (phenotype and etiology of malnourishment)
3. Diagnosis (at least one phenotypic and one etiologic criterion)
4. Severity grading (determination of severity of malnutrition, based on phenotypic criterion.

Question 9

Name examples of somatic, functional, psychological and social factors associated with malnutrition.

Answer 9

• Somatic factors: age, gender, food intake, medication, chewing and swallowing issues, appetite, lab results, diagnosis, body weight (fluctuations), energy expenditure, etc.
• Functional factors: grip strength, gait speed, activity pattern, exercise, etc.
• Psychological factors: motivation, depression, stress, coping with loss, quality of life, loneliness, etc.
• Social factors: financial difficulties, work, education, family, social network, etc.

Question 10

Name nutrition (related) disorders.

Answer 10

• Malnutrition/undernutrition
• Sacropenia and frailty
• Overweight and obesity
• Micronutrient abnormalities
• Refeeding syndrome

Question 11

What is the definition of disease related malnutrition (DMR) with inflammation?

Answer 11

A catabolic condition characterized by an inflammatory response, such as anorexia and tissue breakdown, elicited by an underlying disease.

Question 12

What are characteristics of disease-related malnutrition (DRM) with inflammation?

Answer 12

• Advanced ageing
• Excess fat mass associated with inflammatory response
• Inactivity/bed rest accelerates muscle catabolism during DRM with inflammation

Question 13

Who is at high risk for acute disease-related malnutrition (DRM) with inflammation? Also describe the characteristic pronounced stress metabolism associated with acute DRM with inflammation.

Answer 13

ICU, trauma, sepsis, and patients after major surgical procedures are at risk.
The highly pronounced stress metabolism is associated with:
* high pro-inflammatory cytokine levels
* increased corticosteroid release
* resistance to insuling and growth hormones
* bed rest
* reduced food intake.

Question 14

What are characteristics of chronic disease-related malnutrition (DRM) with inflammation?

Answer 14

End-stage organ diseases that are complicated by catabolic inflammatory responses (cancer, cachexia, Crohn’s disease, COPD, chronic kidney disease etc.).
Characteristics are:
* weight loss
* reduced BMI
* reduced muscle mass and function
* elevated inflammatory activities

Question 15

What is cachexia?

Answer 15

A multifactorial syndrome characterized by an ongoing loss of skeletal muscle mass that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment.

Question 16

Explain in short how tumor progression leads to cachexia.

Answer 16

Tumor cells produce certain factors or interact with certain factors that influence other organs. For example:
* Production of lipid mobilising factors that stimulate fat breakdown.
* Production/interaction of cytokines that influence the brain and liver resulting in anorexia, increased energy expenditure, and the production of acute phase proteins (liver).
* Stimulation of adrenal and B cells that influence insulin, cortisol and glucagon levels. This influences the liver and skeletal muscle, resulting in prodution of acute phase proteins (liver) and protein breakdown (muscle).

Question 17

Describe the characteristics of disease-related malnutrition (DRM) without inflammation.

Answer 17

• Also known as non-cachectic DRM (disease triggered malnutrition without inflammation).
• Mechanisms that can contribute to this disease are: dysphagia, malabsorption, neurologic disorder, dementia, psychiatric conditions, and anorexia of ageing.
• Features include: weight loss, reduced BMI, reduced muscle mass and function, combined with underlying disease.

Question 18

Describe characteristics of malnutrition without disease.

Answer 18

• Hunger-related (e.g. food deprivation)
• Socio-economic or psychological related (e.g. self-neglect, loneliness, loss of spouse, poverty, social inequities)

Question 19

Answer the following question in regard to acute DRM with inflammation, chronic DRM with inflammation, DRM without inflammation, and malnutrition without disease:
* Is inflammation present?
* Is there insulin resistance?
* Is there reduced functionality
* Name an example of patients that present with this disease.

Answer 19

• Acute DRM with inflammation: Yes, Yes, Yes, ICU/trauma/sepsis/major surgery.
• Chronic DRM with inflammation: Yes, Yes, Yes, cancer/Crohn’s disease/COPD.
• DRM without inflammation: No, No, Yes, dysphagia/stroke/anorexia/dementia.
• Malnutrition without disease: No, No, Yes, poverty/self-neglect/loneliness.

Question 20

What is sarcopenia?
And what is primary and secondary sarcopenia?

Answer 20

• Sarcopenia is loss of muscle and strength.
• Primary sarcopenia is due to ageing (age-associated muscle loss)
• Secondary sarcopenia can be due to disease, inactivity, and/or malnutrition

Question 21

What can you do during early-, adult- and older life to maintain as much muscle strength as possible?

Answer 21

• Early life: maximize peak (i.e. maximize the amount of muscle (strength))
• Adult life: maintain peak (e.g. keep exercising)
• Older life: minimize loss

Question 22

So generally, sarcopenia cannot be prevented at older age, where there is a gradual decrease in muscle (strength). However, there is also something called the catabolic crisis model. What is meant by this model?

Answer 22

That acute illness or injury leading to extended bed rest stimulates sarcopenia even further, leading to incomplete recovery, stimulating sarcopenia even further. It can be seen as a vicious circle, where one adverse event leads to more sarcopenia, which leads to more risk for other adverse events, leading to more sarcopenia, etc.

Question 23

Name risk factors of sarcopenia.

Answer 23

• Age-related change in biochemical processes (e.g. sex hormones, apoptosis, mitochondrial dysfunctrion).
• Cachexia
• Starvation, malabsorption
• Endocrine changes
• Disuse (e.g. immobility, inactivity, zero gravity)
• Neurodegenerative diseases (-> motorneuron loss)

Question 24

SARC-F is a screening tool to assess sarcopenia. Five components are measured. Describe these components.

Answer 24

• Strength (how much difficulty lifting and carrying 10 pounds?)
• Assistance in walking (how much difficulty walking?)
• Rise from a chair (how much difficulty transferring from a chair or bed?)
• Climb stairs (how much difficulty climbing stairs?)
• Falls (how many times have you fallen in the past year?)

Question 25

What is the difference between central and sarcopenic obesity?

Answer 25

• Central obesity: accumulation of intra-abdominal fat, associated with higher metabolic and cardiovascular disease risk.
• Sarcopenic obesity: reduced lean body mass regarding adiposity, where obesity exacerbates sarcopenia, increases the infiltration of fat into muscle, lowers physical function and increases risk of mortality.

Question 26

What are five basic mechanisms associated with malnutrition?

Answer 26

1. Insufficient intake where body tissues are catabolized to provide energy.
2. Increased cytokine activity where inflammatory cytokines (e.g. TNF-a, INF-y, IL-6) increase muscle catabolism and inhibit protein synthesis.
3. Inactivity/bed rest reduces muscle loading, inhibiting mTOR dependent protein synthesis.
4. Endocrine action and changes, often resulting in insulin resistance.
5. Neuromuscular atrophy: loss of neural end plates and replacing high tension type II fibers by type I fibers.

Question 27

What factors are important to consider when structuring someone’s nutrition and recovery goals?

Answer 27

• Macronutrients
• Micronutrients
• Medical nutrition
• Taste and/or smell alterations
• Structure
• Number of portions throughout the dat
• Timing