Nutritional history, examination and assessment

Question 1

What are some of the effects of malnutrition?

Answer 1

Impaired survival • Poor wound healing • Anastomotic leaks • Bed sores • Increased sepsis • Poor motivation • Delayed rehabilitation

Question 2

What assessement does NICE recommend for patients with malnutrition to be screened for within 24 hours of admission and weekly?

Does normal BMI(mass/height^2) mean you are fine?

What does the MUST score incoporate?

Answer 2

MUST (Malnutrition Universal Screening Tool)

A person with a normal BMI may lose weight an still remain in the healthy range • Change in weight is important • Acute illness reduces intake too

Must incorporates: BMI score, weight loss score. acute disease effect score

Question 3

What are some limitations of BMI/MUST

Is obesity a malnourishment>

Answer 3

• Pregnancy
• Muscle weight
• Fluid increase (oedema)
• Poor intake from chronic illness

Calorific excess, may hide micronutrient and vitamin deficiencies • Loss of weight in the obese may be obscure • Obese patients very rarely appear ‘classically malnourished’

Question 4

This was under the stoma bag

Caused by

Answer 4

Proximal fistula

• High output: fluid and electrolyte losses
• Short bowel syndrome

Question 5

What is anthropometrics

What are the problems with it?

Answer 5

Useful for research not for standard clinics

• Like weight, a change is better than one off measurements • Inter-observer variation • Intra-observer variation • Must use non-stretch tape-measure • Time consuming

Question 6

How can you work out someone’s strength?

Answer 6

• Non-dominant hand • Functional measure of nutritional status • Correlates well with nutritional depletion and repletion • Less intra and interobserver variation

Question 7

What are ways to examine someone’s nutritional status?

Answer 7

Change in clothes/dress size

• Belt notches
• Denture fit - if they don’t fit the
• Temporalis wasting - waste really quickly when you arent eating. Hollowing out seen in annorexia patients.
• Skin lesions - e.g petechial haemorrhages in scurvy

Question 8

This person was living off of tea and biscuits. Socially isolated. What does this person have?

Answer 8

Scurvy

Question 9

Why should you not rely upon serum markers?

Why should you not measure trace elements?

Why does serum iron fall after acute inflammation?

What happens copper levels rise due to inflammation?

Answer 9

Albumin, and other serum protein markers all have marked limitations

• All are affected by active inflammation
• Albumin also affected by intravenous fluids and liver dysfunction
• Albumin has a half life of 21 days - takes a while to restore .
• Many patients with severe malnutrition e.g. anorexia nervosa patients with BMI <14 regularly have normal albumin levels

All affected by acute inflammation:

– Iron bound into cells, so serum levels fall – Copper levels rise (toxic to bacteria)

• Vitamin levels similarly affected, and for example the RDA of vitamin C has over the years ranged from 30-120mg/day

Question 10

What scans can be used to detect muscle loss?

Answer 10

DEXA(• Dual energy x-ray absorbitometry )

• Differentiates fat-mass from lean-mass and bone mass • Increase in extracellular fluid appears as leanmass • This can be overcome by using body water measurements but this becomes very complicated

CT - new software can differentiate adipose and other tissue - still a research tool

Bioelectrical impedance analysis

-Can determine fat free mass, total body water, intra-cellular and extra-cellular water in an individual with no disturbance in water and electrolytes. • Determined by using multiple frequencies of current and noting the impedance • Relies on using an appropriate population, age and pathology specific equations

Portable, cheap and acceptable to the patient • Clinical use at extremes of BMI (34) or abnormal hydration cannot be recommended • Interpretations in acute illness still being determined • Useful clinical research technique but not validated for routine clinical use

Question 11

Dietary history

How can we ask diet questions?

Answer 11

Recollection marred with recall bias – Can you re-call what you ate every day for the last week?

• Dietary questionnaires have to have reproducibility and validity
• On the ward (and OP), diaries completed
• What is a portion and how does that translate to real life?

Pictures of food • Models of food • Weighed record most accurate but quite impractical

• Food bought record (supermarket loyalty card) does not take into account amount never cooked or food cooked then not eaten)

Check for alcohol history and hydration. See what they had for breakfast lunch and dinner

• Use dietary history sheet

Use red trays/jugs and beakers