Nutrition and Weight Loss Flashcards
What are the 10 key recommendations from the Lancet review on malnutrition in the elderly?
- Routinely screen for malnutrition using validated tool
- If positive screen = systematic assessment
- Serum albumin = influenced by inflammation = not good biomarker
- Nutritional care individual and comprehensive
- Nutritional care multidisciplinary approach
- If risk/dx give nutritional info, education, counselling
- Avoid dietary restrictions (only if obese)
- Oral nutritional supplement offer to all if risk/dx when fortification/counselling insufficient
- Support by food modification
- In LTC/home care = meal time assistance
What does malnutrition put patients at risk for?
Frailty
Muscle wastage
Osteoporosis
CI
Delirium
Mood changes
Hypothermia
Low QOL
Mortality
What can delayed tx of malnutrition result in?
Poor wound healing
Pressure sores
Falls
Hospitalization
Institutionalization
What is the prevalence of malnutrition?
Community 3.1%
Home care 8.7%
Hospital 22%
LTC 28.7%
What are the three etiologic subtypes of malnutrition?
- Disease related driven by inflammation (COPD, CHF, CKD)
- Disease related not with inflammation (stroke, PD, dementia)
- Malnutrition without disease (hunger, SES, psychologic)
What are risk factors for malnutrition?
- Eating problems (low appetite, dependency)
- Low physical function (ADL, strength)
- Poor self-perceived health
- Previous hospital admission
- Poor oral health
- Loss of interest in life
- Marital status
What dietary recommendations can help prevent malnutrition?
Protein 1 g/kg per day (1.2-1.5 chronic or acute illness, up to 2)
Energy >30 kcal/kg/day
Who should you screen for malnutrition and how?
Routinely screen ALL older adults
Identify those malnourished or at risk
No gold standard for diagnosis
Tools
Community: Determine your nutritional health checklist
Hospital: MNA-SF, Nutritional risk screening
Residential: Short Nutritional assessment questionnaire
What are the components of the Mini Nutritional Assessment short form?
- Decline in food intake over last 3 mos (appetite, digestive, chew, swallow)
- Involuntary weight loss 3 mos
- Mobility status
- Psych stress or acute illness 3 mos
- Neuropsych (depression, dementia)
- BMI (or calf circumference)
What are four nutritional deficits that may be associated with frailty?
B12
Vit C, D, E
Folate
Low protein intake
What are 3 clinical assessments used in nutrition screening for older adults?
Subjective global assessment
Malnutrition screening tool
Mini Nutritional Assessment
What are anthropometric measures used to assess nutritional status in older adults?
BMI
Ideal body weight
Adjusted body weight
Calf circumference
Skin fold thickness
What are changes with aging that make BMI cutoffs less useful in older adults?
Small proportion of lean body mass
Shorten due to kyphosis
What are non-pharmacologic tx for unintentional weight loss?
Minimize restrictions
Optimize energy intake
More frequent small meals
Favourite foods and snacks
Finger foods
Avoid gas producing foods
Adequate oral health
High energy supplements
Supplements between meals
Eat with company
Eat with assistance
Flavour enhancers
Regular exercise
Vitamin supplement daily
Community nutritional support services
Weighted utensils
What are the diagnostic criteria for malnutrition in older adults as per 2018 Global leadership guidelines?
Must have at least 1 phenotypic criterion and 1 etiologic criterion
Phenotypic Criterion
1. Non volitional weight loss
>5% in last 6 months
>10% in more than 6 months
2. Low BMI
<20 if <70
<22 if >70
3. Reduced muscle mass: by validated body composition measuring techniques ex. DXA, FFMI (fat free mass index), CT, MRI
Etiologic Criterion
1. Reduced food intake or assimilation
<=50% of ER > 1 week, or any reduction for >2 weeks, or any chronic GI condition that adversely impacts food assimilation or absorption
2. Disease burden/inflammatory condition (acute disease/injury or chronic disease related)
List 6 physiologic changes in aging that can contribute to weight loss
- Impaired taste/smell
- Neuroendocrine dec appetite and early satiety (low ghrelin, high leptin, high fasting and post prandial insulin)
- Delayed gastric motility/emptying
- Reduced chewing/poor dentition
- Less high metabolic needs activities = less drive to eat
- Dec muscle mass
- Less able to adapt to periods of over/under eating
- Chronic low grade inflammation = appetite suppression
What to look for on home OT assessment if weight loss?
Quantity of food in the fridge/pantry
Nutritional value of food present
Presence of spoiled food
Ability to use appliances, utensils etc.
Medications - pill bottles, organizational method, expiration date
State of cleanliness of house/kitchen
Access to transportation/mobility to go buy food
Mobility/gait aid/assistive devices
What 4 medications can cause B12 deficiency?
- PPI
- H2 blockers
- Metformin
- Colchicine
What lab changes occur with refeeding syndrome?
LOW
Potassium
Mg
PO4
Thiamine
HIGH
Sodium
Due to increased nutrition following starvation, fluid and electrolyte shifts
What are 5 reasons why older adults have difficulty with water balance?
Decreased thirst sensation
Lack of urine concentrating abilities of kidneys
CI - forget to drink
Immobile - unable to get water
DM - diuretic effect of glucosuria
What are the two most common causes of B12 deficiency in older adults?
- Food cobalamin malabsorption syndrome (gastric atrophy = unable to release B12 from food or intestinal transport proteins)
- Pernicious anemia
What are the 4 steps involved in B12 ingestion to absorption?
- Pepsin and HCl sever bond between cobalamin and animal protein
- Cobalamin binds to R protein (parietal and salivary cells) to protect from stomach breakdown
- Pancreas secretes protease to sever bond between R protein and cobalamin
- Intrinsic factor from stomach binds to cobalamin in SI and then absorb in TI
- Cobalamin binds to transcobalamin II in intestinal cell, carried through blood to end organs, stored in liver
What are pharmacologic treatment options for poor oral intake?
- Multivitamin
- Calcium target 1200 mg
- Vitamin D 1000 U
- Iron, B12 PRN
- Megestrol acetate - HIV, br and endometrial ca
- Dronabinol - cannabinoid
- Ghrelin - sfx hyperglycemias, dizzy, nausea
- Mirtazapine
What are 6 health effects of B12 deficiency?
- Macrocytic anemia
- Glossitis
- Subacute combined degeneration of dorsal and lateral columns of spinal cord (demyelination)
- Peripheral neuropathy
- Cognitive changes
- Depression/mood changes
What are 6 mechanisms to associate hyperhomocysteinemia with AD?
- HHCY = risk stroke = vascular
- HC = oxidative stress = tau phosphorylation = tangles = neurodegeneration
- HC = oxidative stress = beta amyloid cleavage = neurodegeneration
- HC = oxidative stress = MMP activation = vascular inflammation and endothelial cell disruption = BBB disruption
- Apoptosis
- Neuronal death
What are confounders that could account for studies showing vit D deficiency causing inc risk of dementia?
Age of patients
Season/location
Education level
Alcohol
Smoking
What are common medical causes of weight loss?
- Malignancy
- Psych disorder (depression)
- GI illness
- Endocrine disorder
- CVD
- Nutritional disorder or alcoholism
- Respiratory disease
- Neurologic disorder
- Chronic infection
- Drug induced
What are the 2 questions posed by the Canadian Nutrition Screening Tool?
- Have you lost weight in the past 6 months without trying?
- Have you been eating less than usual for more than 1 week?
What is optimal BMI for elderly?
Older adults with BMI <25 and >35 kg/m2 were at a higher risk of a decrease in functional capacity, and experienced gait and balance problems, fall risk, decrease in muscle strength, and malnutrition.
optimum range of BMI levels for older adults is
* Female 31–32 kg/m2
* Male 27–28 kg/m2
