Nutrition Flashcards
What is malnutrition?
The National Institute for Health and Care Excellence (NICE) defines a person as being malnourished if they have: a body mass index (BMI) of less than 18.5 kg/m2 unintentional weight loss greater than 10% within the past 3–6 months
Malnutrition is common, under-recognised condition in hospital patients. It is both a cause
and consequence of disease and exists in care homes, communities and in hospitals.
When should MUST be used to screen for malnutrition?
It should be done on admission to care/nursing homes and hospital, or if there is concern.
For example, an elderly, thin patient with pressure sores it takes into account BMI, recent weight change and the presence of acute disease categorises patients into low, medium and high risk
What does NICE recommend in terms of malnutrition?
Dietician support if the patient is high-risk a ‘food-first’ approach with clear instructions (e.g. ‘add full-fat cream to mashed potato’), rather than just prescribing oral nutritional supplements (ONS) such as
Ensure if ONS are used they should be taken between meals, rather than instead of meals
Causes of malnutrition?
Inadequate amounts of nutrients (e.g. poor variety in diet, cognative impairment)
Difficulty absorbing nutrients (e.g. gastrointestinal dysfunction such as coeliac disease)
Increased nutritional demands (e.g. post-surgery for healing)
Risk factors for malnutrition?
Those most at risk of malnutrition are patients with chronic illnesses, the elderly, those living in supported accommodation and patients drinking excessive amounts of alcohol over a prolonged period.
Other risk factors for malnutrition include:
Being hospitalised for extended periods of time
Problems with dentition, taste or smell
Polypharmacy
Social isolation and loneliness
Mental health issues including grief, anxiety and depression
Cognitive issues including confusion
Consequences of malnutrition?
Muscle function - low skeletal muscle mass
Bardycardia, hypotension, hypothermia
Loss of fitness
Constipation
Depletion of subcutaneous fat stores
Impaired wound healing
Psychosocial effects
Multi organ failure
Death
What validated screening tools exist for malnutrition?
MUST, MST and MNA
What does MUST involve?
It involves a five-step screening
tool to identify adults, who are malnourished, at risk of malnutrition (undernutrition), or
obese by incorporating current weight (BMI), history of unintentional weight loss, likelihood
of future weight loss.
It is used in hospitals, community and other care settings and can be used by all care workers
Stages of wound healing?
Haemostasis – the action of platelets and cytokines forms a haematoma and causes vasoconstriction, limiting blood loss at the affected area
Inflammation – a cellular inflammatory response acts to remove any cell debris and pathogens present
Proliferation – cytokines released by inflammatory cells drive the proliferation of the fibroblasts and the formation of granulation tissue
Angiogenesis is promoted by the presence of growth mediators (e.g VEGF), allowing for further maturation of the granulation tissue; the production of collagen by fibroblasts allows for closure of the wound after around a week
Remodelling – collagen fibres are deposited within the wound to provide strength in the region, with the fibroblasts subsequently undergoing apoptosis
Serum albumin and malnutrition?
Hypoalbuminaemia occurs in conditions where there is an excessive amount of protein being lost (e.g. protein-losing enteropathy, chronic renal disease) or where the production of albumin is impaired (e.g. liver disease due to loss of synthetic function or malnutrition due to a paucity of protein). Hypoalbuminaemia can also develop in the context of inflammatory states such as infections. As a result, serum albumin should not be relied on in isolation to assess a patient’s nutritional state as there are a wide variety of factors which influence levels.
Important aspects of a nutrition history?
Weight history: including current weight, recent changes to weight and changes to fit of clothes
Meal history: regularity of meals including skipping meals
Protein intake: intake of high-quality protein
Hydration: intake of fluids
Clinical examination of a patient with suspected malnutrition should include what?
Weight: unexpected weight loss from someone’s normal weight is indicative of a period of malnutrition. This includes people who are clinically overweight and obese.
Body mass index (BMI): a patient’s BMI indicates whether they might be malnourished. It is not however as accurate as history and clinical examination, and should never be used in isolation.
Review of muscle mass stores
Review of subcutaneous fat stores
Consideration could also be given to measuring a patient’s grip strength, triceps skin fold thickness and mid-arm muscle circumference
Methods of feeding?
Oral nutrition should be used as long as it is possible, with the use of oral nutritional support such as high-energy-high-protein supplements and fortified food products. Often, minor changes to diet will have a significant positive impact on a patient’s nutritional status.
If a patient is unable to safely swallow or is unable to take sufficient calories orally, nasogastric feeding should be considered. For long-term feeding, a gastrostomy (PEG or RIG) or jejunostomy should be considered.
Parenteral nutrition should be reserved for patients with intestinal failure or inaccessible digestive tracts.
What is refeeding syndrome and how can it be prevented?
Refeeding syndrome is a condition caused by a rapid re-introduction of normal nutrition in patients who are chronically malnourished. In the context of chronic malnutrition, a patient’s intracellular stores of key electrolytes such as potassium and phosphate become depleted. As a result, if a patient is suddenly provided with normal levels of nutrition, there is a sudden shift of these electrolytes from the extracellular to the intracellular compartment driven by a large insulin response and other factors. This can ultimately lead to a sudden drop in extracellular levels of key electrolytes resulting in hypokalaemia and hypophosphataemia. This can subsequently lead to cardiac complications (e.g. arrhythmias) and seizures.
To prevent refeeding syndrome, nutrition is re-introduced more gradually under the guidance of a dietician and the patient’s electrolytes are monitored closely, allowing deficiencies to be identified early and replaced appropriately.
Local factors that might affect wound healing?
Oxygenation (cell proliferation, angiogenesis, protein synthesis)
Infection (increases inflammation)
Foreign body (prolongs inflammatory response)
Venous insufficiency (reduced flow of oxygen)
Eatwell plate
potatoes, bread, rice, pasta and other starchy carbohydrate foods should range to 38% of total food consumption
fruit and vegetables should be the highest with 40% dairy and alternatives foods account for 8% of total consumption
beans, pulses, fish, eggs, meat and other protein should be around 12%
oils and spreads are to be consumed less often in small amount this 1%
