Malnutrition Screening and Assessment

Question 1

How does the onset of an inflammatory process begin?

Answer 1

With an insult to the body from pathogens, trauma, or other disease-causing agents

Question 2

The inflammatory response increases cytokine production which in turn does what?

Answer 2

Signals hepatocytes to suppress the production of negative acute-phase proteins in favor of freeing amino acids for production of positive acute-phase proteins

Question 3

What are the 5 components of the SGA that consider medical history, and the 3 components that focus on physical examination?

Answer 3

Medical history: weight changes, dietary intake, GI symptoms, functional capacity, metabolic stress from disease
Physical: muscle wasting, fat depletion, nutrition-related edema

Question 4

According to Subjective Global Assessment (SGA) criteria, what severity of malnutrition best describes a patient who presents with cirrhosis complicated by portal hypertension, ascites, and edema?
Scenario: 52 y/o M h/o cirrhosis and portal hypertension r/t etoh abuse, 10 lb gain in 2 weeks with massive ascites, mild encephalopathy, asterixis, scleral ictus. Normal temp, low albumin, low prealbumin, normal WBC, elevated bilirubin and LFTs. Poor intake for at least 1 month (<50% of usual intakes), chronic early satiety, loss of appetite, diarrhea from lactulose. 150 lb usual weight, present weight 161 lb. 3-4+ LLE edema. severe fat loss in triceps and chest, severe muscle wasting in deltoids

Answer 4

Patient’s SGA ranging is C severely malnourished, as defined by his poor nutrition intake, muscle wasting, and loss of subcutaneous fat; supported by data showing his decreased functional capacity, persistent GI symptoms for >2 weeks, and increased metabolic demand. Nutrition intervention aimed at promoting adequate energy intake with balanced macronutrients, sodium restriction, replacement of appropriate micronutrients. May benefit from protein-energy supplements and vitamin/mineral replacement

Question 5

Common medical/surgical diagnoses associated with heightened and intense inflammatory response with an acute injury/illness etiology of malnutrition

Answer 5

Critical illness, major infection/sepsis, adult respiratory distress syndrome, systemic inflammatory response syndrome, severe burns, major abdominal surgery, multitrauma, closed head injury, severe acute pancreatitis, post-op ileus

Question 6

Common medical/surgical diagnoses associated with mild to moderate inflammatory response with a chronic illness (>3 months) etiology of malnutrition

Answer 6

Cardiovascular disease, CHF, cystic fibrosis, inflammatory bowel disease, celiac disease, chronic pancreatitis, rheumatoid arthritis, solid tumors, hematologic malignancies, sarcopenic obesity, DM, metabolic syndrome, CVA, neuromuscular disease, dementia, organ failure/transplant of kidney liver heart lung or gut, periodontal disease, pressure wounds, COPD, HIV, lupus, SBO, prolonged ileus

Question 7

Common medical/surgical diagnoses associated with no inflammatory response with a social/behavioral/environmental circumstance etiology of malnutrition

Answer 7

Starvation, anorexia nervosa, compromised food intake in the setting of financial disparity, dementia, alcohol/drug abuse, pain, SBO

Question 8

Suggested biochemical data parameters to assess for the presence of inflammation

Answer 8

Depleted albumin, prealbumin, transferring; elevated CRP, ferritin; hyperglycemia; leukocytosis, leukopenia, thrombocytopenia

Question 9

Suggested microbiological data parameters to assess for the presence of inflammation

Answer 9

Urine cultures (UTI), blood cultures (bloodstream infections), fecal cultures (GI infections), bodily fluid cultures (infected abscess, pleural fluid, sputum, ascites)

Question 10

Suggested imaging parameters to assess for the presence of inflammation

Answer 10

Chest xray (pneumonia, infiltrations, inflammation); CT, MRI, PET scan, abdominal/pelvic xray (abscess, pancreatitis, cancer, inflammatory process, bowel obstruction); gastric emptying study/small bowel follow-through (gastroparesis, dysmotility); EGD/colonoscopy (IBD, radiation enteritis, GVHD, gastritis, ulcers, fistula, strictures); ECHO (vegetation, endocarditis)

Question 11

Suggested clinical manifestation parameters to assess for the presence of inflammation

Answer 11

Fever, hypothermia, chills, night sweats
Tachycardia, low BP
Rashes, skin redness, swelling, tenderness
Discharge from eyes or nose
Swelling or redness of mouth/gums
Pain with urination, productive cough, burns

Question 12

What kind of factors can skew measures of weight?

Answer 12

Dehydration, excessive fluid accumulation, tumors

Question 13

List the time frame and percentage of meaningful weight loss for moderate and severe acute illness/injury malnutrition

Answer 13

Moderate: 1-2% in 1 week, 5% in 1 week, 7.5% in 3 months
Severe: >2% in 1 week, >5% in 1 month, >7.5% in 3 months

Question 14

List the time frame and percentage of meaningful weight loss for moderate and severe chronic illness malnutrition

Answer 14

Moderate: 5% in 1 month, 7.5% in 3 months, 10% in 6 months, 20% in 1 year
Severe: >5% in 1 month, >7.5% in 3 months, >10% in 6 months, >20% in 1 year

Question 15

List the time frame and percentage of meaningful weight loss for moderate and severe social/environmental circumstance malnutrition

Answer 15

Moderate: 5% in 1 month, 7.5% in 3 months, 10% in 6 months, 20% in 1 year
Severe: >5% in 1 month, >7.5% in 3 months, >10% in 6 months, >20% in 1 year

Question 16

What is the NUTRIC score?

Answer 16

Nutrition Risk in Critically Ill. Focuses on severity of illness using APACHE II, SOFA (with or without IL-6), number of comorbidities, days from hospital to ICU admission. Predictive of 28-day mortality. Recommended to assist with identification of critically ill patients most likely to gain from aggressive nutrition interventions

Question 17

Describe the effect of starvation on lean muscle mass and adipose stores?

Answer 17

Preservation of LBM is the ultimate goal. Glycogen is initially used as the primary energy source, but reserves are quickly depleted forcing the body to use amino acids to make glucose and support energy requirements. Eventually, further adaptation occurs and resting energy expenditure decreases as fat becomes the main energy source providing ketones as fuel as a means to preserve muscle mass

Question 18

Describe the effects of the metabolic pathway of inflammation/stress response on lean muscle mass and adipose stores?

Answer 18

Characterized by extreme catabolism and negative nitrogen balance, driven by a storm of hormones and cell mediators to mount an immune defense and repair tissue during injury and illness. All these reactions accelerate muscle breakdown to generate energy. Amino acids are displaced from muscles and used for gluconeogenesis. Additionally, cytokines act to inhibit repair and synthesis of new muscle tissue, promote muscle breakdown, and affect muscle function. Muscle degradation continues unabated while the condition persists, creating a much faster rate of skeletal and lean muscle loss than seen in starvation. The stress response mechanisms also work against nutrition intervention aimed at preservation.

Question 19

What is muscle atrophy?

Answer 19

Loss of bulk and tone that is detectable by palpation

Question 20

Define sarcopenia and its etiology

Answer 20

The age-related loss of muscle mass and has been associated with a decline in function. Various etiologies such as inflammatory and cytokine-driven oxidative stress as well as protein synthesis and neuromuscular integrity

Question 21

Name conditions that affect sarcopenia

Answer 21

Lack of muscle use, chronic disease, insulin resistance, and poor nutrition

Question 22

Define cachexia

Answer 22

Loss of muscle mass, irrespective of adipose tissue changes, which accompanies underlying illnesses and is often associated with inflammation, insulin resistance, decreased appetite and intake, and protein catabolism

Question 23

Is cachexia responsive to nutrition support?

Answer 23

No because of its multifaceted and profound inflammatory state. Symptom management is imperative