The basics of nutrition and the diagnosis of malnutrition Flashcards
Nutrition definition
“The branch of science that studies the process by which living organisms take in and use food for the maintenance of life, growth, reproduction, the functioning of organs and tissues, and the production of energy.”
Macronutrients
protein, fats, carbohydrates. Required in gram amounts and are major sources of energy and amino acids.
Micronutrients
– vitamins, minerals, trace elements. Minerals required in gram or milligram amounts, trace elements required in microgram amounts
Assessment of nutritional status
NICE CG32 states that:
- All hospital inpatients and all outpatients at their first clinic appointment should be screened. This should be repeated weekly for inpatients and when there is clinical concern for outpatients
- Groups of patients considered to be low risk may be opted out. There must be an explicit process for opt-out decisions within a clinical governance structure
- People in care homes to be screened on admission and where there is clinical concern
- Screening upon registration at GP surgeries and when there is clinical concern
- Screening should also be considered at other opportunities (e.g. health checks, flu injections)
- Screening should assess:
- BMI
- % unintentional weight loss
- Suggested tool is (MUST) as developed by BAPEN
What is ‘MUST’ tool
- ‘MUST’ is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition (undernutrition), or obese. It also includes management guidelines which can be used to develop a care plan.
- It is for use in hospitals, community and other care settings and can be used by all care workers
Nutrition support should be considered in people who are malnourished, as defined by any of the following
a BMI of less than 18.5 kg/m2
unintentional weight loss greater than 10% within the last 3–6 months
a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.
For people who are not severely ill or injured, nor at risk of refeeding syndrome, the suggested nutritional prescription for total intake[7] should provide all of the following:
25–35 kcal/kg/day total energy (including that derived from protein)
0.8–1.5 g protein (0.13–0.24 g nitrogen)/kg/day
30–35 ml fluid/kg (with allowance for extra losses from drains and fistulae, for example, and extra input from other sources – for example, intravenous drugs)
adequate electrolytes, minerals, micronutrients (allowing for any pre-existing deficits, excessive losses or increased demands) and fibre if appropriate.
Criteria for determining people at high risk of developing refeeding problem
Patient has one or more of the following:
- BMI less than 16 kg/m2
- unintentional weight loss greater than 15% within the last 3–6 months
- little or no nutritional intake for more than 10 days
- low levels of potassium, phosphate or magnesium prior to feeding.
Or patient has two or more of the following:
- BMI less than 18.5 kg/m2
- unintentional weight loss greater than 10% within the last 3–6 months
- little or no nutritional intake for more than 5 days
- a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics.
The prescription for people at high risk of developing refeeding problems should consider:
starting nutrition support at a maximum of 10 kcal/kg/day, increasing levels slowly to meet or exceed full needs by 4–7 days
using only 5 kcal/kg/day in extreme cases (for example, BMI less than 14 kg/m2 or negligible intake for more than 15 days) and monitoring cardiac rhythm continually in these people and any others who already have or develop any cardiac arrythmias
restoring circulatory volume and monitoring fluid balance and overall clinical status closely
providing immediately before and during the first 10 days of feeding: oral thiamin 200–300 mg daily, vitamin B co strong 1 or 2 tablets, three times a day (or full dose daily intravenous vitamin B preparation, if necessary) and a balanced multivitamin/trace element supplement once daily
providing oral, enteral or intravenous supplements of potassium (likely requirement 2–4 mmol/kg/day), phosphate (likely requirement 0.3–0.6 mmol/kg/day) and magnesium (likely requirement 0.2 mmol/kg/day intravenous, 0.4 mmol/kg/day oral) unless pre-feeding plasma levels are high. Pre-feeding correction of low plasma levels is unnecessary.
Obvious indicators of dysphagia
Difficult, painful chewing or swallowing
Regurgitation of undigested food
Difficulty controlling food or liquid in the mouth
Drooling
Hoarse voice
Coughing or choking before, during or after swallowing
Globus sensation
Nasal regurgitation
Feeling of obstruction
Unintentional weight loss – for example, in people with dementia
Less obvious indicators of dysphagia
Change in respiration pattern
Unexplained temperature spikes
Wet voice quality
Tongue fasciculation (may be indicative of motor neurone disease)
Xerostomia
Heartburn
Change in eating habits – for example, eating slowly or avoiding social occasions
Frequent throat clearing
Recurrent chest infections
Atypical chest pain
Vitamin D is converted to
25hydroxyVitaminD in the
liver and then on to 1,25-dihydroxyVitaminD in the kidney. It is this
which has potent metabolic effects
There are two types of Vitamin D:
- Ergocalciferol (Vitamin D2) a plant product and
-Colecalciferol (Vitamin
D3) which is a fish or mammal
product.
what should not
be used for the treatment of simple Vitamin D deficiency.
‘Activated Vitamin D’ preparations such as Calcitriol or Alfacalcidol.
They are ineffective in treating simple Vitamin D deficiency and can cause severe adverse effects, particularly hypercalcaemia.
Vit D ‘insufficiency’
between 25 and 50 nmol/L
at risk of Vitamin D deficiency
1. increased need: • pregnant and breastfeeding women • infants • twin and multiple pregnancies • adolescents • obesity
- Reduced sun exposure:
• northern latitude, especially above 50 degrees latitude (eg UK)
• season – in winter and spring
• Asian and African people – dark skin needs more sunshine to
make Vitamin D
• wearing concealing clothing
• immobility, eg inpatients or those with conditions like cerebral
palsy
• excessive use of sun block – most block UVB more than UVA - Limited diet (but remember sunshine is most important source
of Vitamin D):
• vegetarians and vegans
• prolonged breastfeeding – even if mother has sufficient Vitamin D
• exclusion diets – eg milk allergy
• malabsorption
• liver disease
• renal disease
• some drugs – eg Anticonvulsants, Anti-TB drugs
The Department of Health and the Chief Medical Officers recommend a
dose of 7-8.5 micrograms (approx 300 units) for ALL children from six
months to five years of age
high level of PTH is usually due to
Vitamin D deficiency or a lack of Calcium in the diet. Other causes (eg parathyroid tumours or renal failure) are rare
COMA used four types of Dietary Reference Values:
Estimated Average Requirements (EARs)
The EAR is an estimate of the average requirement of energy or a nutrient needed
by a group of people (i.e. approximately 50% of people will require less, and 50% will
require more).
Reference Nutrient Intakes (RNIs)
The RNI is the amount of a nutrient that is enough to ensure that the needs of
nearly all a group (97.5%) are being met.
Lower Reference Nutrient Intakes (LRNIs)
The LRNI is the amount of a nutrient that is enough for only a small number of
people in a group who have low requirements (2.5%) i.e. the majority need more.
Safe Intake
The Safe intake is used where there is insufficient evidence to set an EAR, RNI or
LRNI. The safe intake is the amount judged to be enough for almost everyone, but
below a level that could have undesirable effects.
Step 1 of MUST tool
Step 1: Measure height and weight to get a BMI score using chart provided. If unable to obtain height and weight, use the alternative procedures shown in this guide. BMI kg/m2
BMI >20(>30 Obese) = Score 0
BMI 18.5 -20 = Score 1
BMI <18.5 = Score 2
Step 2 of MUST tool
Step 2: Note percentage unplanned weight loss and score using tables provided.
% Score
<5 = 0
5-10 = 1
>10 = 2
Step 3 of MUST tool
Step 3: Establish acute disease effect and score.
- If patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days give Score of 2
Step 4 of MUST tool
Step 4: Add scores from steps 1, 2 and 3 together to obtain overall risk of malnutrition.
Score 0 Low Risk:
Repeat screening: Hospital – weekly, Care Homes – monthly, Community – annually for special groups e.g. those >75 yrs
Score 1 Medium Risk:
Document dietary intake for 3 days if subject in hospital or care home. If improved or adequate intake – little clinical concern; if no improvement – clinical concern - follow local policy
Repeat screening: Hospital – weekly, Care Home – at least monthly, Community – at least every 2-3 months
Score 2 or more High Risk:
Refer to dietitian, Nutritional Support Team or implement
local policy.
Improve and increase overall nutritional intake
Monitor and review care plan: Hospital – weekly, Care Home – monthly, Community – monthly
Step 5 of MUST tool
Step 5: Use management guidelines and/or local policy to develop care plan.
