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Undernutrition Flashcards

1
Q

What is undernutrition?

A

Undernutrition is a lack of energy/nutrient intake to maintain health/ meet demands/ maintain homeostasis.

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2
Q

What is the current prevalence of undernutrition in the UK?

A

(BAPEN, 2018)
* 3 million people malnourished
* Elderly (>65) most affected, 1.3 million
*30-42% of patients admitted to care homes at risk
*25-34% of patients admitted to hospital at risk
*18-20% of patients admitted to mental health units at risk
*10-14% in sheltered housing at risk

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3
Q

Name some of the signs of undernutrition

A

Signs of undernutrition
* Weight loss (doesn’t always occur)
* Muscle strength loss
* Dry, thin, brittle hair
* Cracked/ dry nails
* Xerosis (dry skin)
* Loose/poor fitting dentures
* Loose/poor fitting clothes/jewellery
* Reduced appetite
* Lack of interest in food/drink
* Tiredness/Lethargy
* Falls
* Dysphagia
* Prolonged wound healing
* Reduced ability to perform normal tasks
* Poor concentration
* Poor growth in children
* Mood changes: depression

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4
Q

Scientific

What are the 5 causes of undernutrition?

A

The 5 causes of undernutrition (scientific)
* Decreased dietary intake
* Increased nutritional requirements/metabolic demands
* Impaired nutrient absorption
* Impaired nutrient utilization
* Excessive loss of nutrients

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5
Q

What are the 12 main causes of decreased dietary intake?

A

12 main causes of decreased dietary intake:
* Modified consistency diets
* Food neophobia: particularly in small children & older adults
* Food insecurity
* Poor presentation, taste, flavour
* Lack of cooking knowledge
* Hospitals/care homes: foods that meet religious/cultural requirements not provided.
* Social isolation/loneliness
* Excess alcohol consumption
* Issues with mouth/swallowing
* Low mood
* Lack of assistance
* Interrupted meal times

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6
Q

What did **Capiola et al., 2016 **find about food neophobia and older adults?

A

Capiola et al., 2016 found that food neophobia was reported to significantly reduce the intake of 20 nutrients in older adults.

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7
Q

What did SACN, 2021 find about decreased energy intake?

A

SACN, 2021 found that:
* OAs aged 65-74 had lower energy intake than 19-64
* >/= 75 had lower energy intake than 65-74
* >/= 75 lower mean percentage protein intakes than 65-74
* Protein intakes per kg body weight were lower in older age groups

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8
Q

What are the 9 D’s?

A

The 9 D’s:
* Dentition
* dysgeusia (impaired sense of taste)
* dysphagia
* diarrhoea
* disease
* depression
* dementia
* dysfunction
* drugs
* dependency for eating

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9
Q

What did Nieuwenhuizen 2010 find about environmental factors and dietary intake?

A

Nieuwenhuizen 2010 found that environmental factors can increase or decrease dietary intake.

Increase dietary intake:
* Consistent meal times
* Eating with others
* Encouragement from care givers
* Easy access to food
* Eating whilst watching TV

Decrease dietary intake:
* Living alone
* Social isolation
* Unprotected/interrupted meal times
* Lack of assistance
* Inappropriate meal times

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10
Q

________________ adults need more _____________ than _______________ adults

A

Older adults need more protein than younger adults

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11
Q

Which age group (s) are more vunerable to the impact of low intakes?

A

Babies and infants are more vunerable to the impact of low dietary intake as they lack the same storage as adults (Langley-Evans, 2021)

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12
Q

Three main states that there is increased demand?

A

Three main states that there is increased demand:
* Trauma
* Pregnancy
* Lactation

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13
Q

Conditions with increased demand
(Lecture slides)

A

Conditions with increased demand:
* Neurological conditions (e.g. Parkinson’s)
* Chronic conditions (e.g. cancer)
* Pressure sores/wounds
* Wound healing/recovery
* Disease

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14
Q

In which conditions is malabsorption an independent risk factor for weight loss and undernutrition?

A

Malabsorption is an independent risk factor for weight loss and undernutrition in:
* Intestinal failure
* Abdominal surgical procedures

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15
Q

Which types of conditions can increase risk of undernutrition?

A

Gastroenterological conditions can increase undernutrition risk due to malabsorption caused by inflammation.

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16
Q

Excessive nutrient loss occurs via:

A

Excessive nutrient loss occurs via:
* Vomiting
* Diarrhoea
* Enterocutaneous fistulae
* Burns
* Excess diuretic use

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17
Q

What is the cost of undernutrition to the NHS?

A

Undernutrition costs the NHS £23.1 billion

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18
Q

What are the consequences of undernutrition?

A

Consequences of undernutrition:
* Weight loss
* Muscle loss: cardiac, respiratory
* Stunted growth
* Diminished functioning of GI tract: poor muscle and Villi function, enteropathy> increased likelihood of toxin entry >poor absorption & poor function
* Reduced immune function
* Poor wound healing
* Low Mg, K, Phosphate. High sodium & water> refeeding syndrome risk
* Depression
* Poor thermoregulation
* Pressure sores/ulcers

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19
Q

When does starvation lead to death?

A

Starvation > death
* 40% weight loss in acute starvation
* 50% in prolonged starvation
* obese individuals: 65-80% weight loss

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20
Q

How can loss of muscle mass be detected?

A

Loss of muscle mass can be detected with the grip strength test.

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21
Q

Describe the Malnutrition Carousel (BAPEN, 2018)

A

The Malnutrition Carousel (BAPEN, 2018)
* 24%-34% of hospital admissions at risk of undernourishment
* People who are malnourished/at risk have: longer stays, are more likely to need care and support upon discharge
* 70% of patients weigh less when they are discharged
* GP visits, hospital admissions, prescriptions increase

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22
Q

What can cardiac failure cause?

A

Cardiac failure can cause cachexia.

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23
Q

What is a pressure ulcer/sore?

A

Pressure ulcer/sore:
* Area of damaged skin & underlying tissue
* Caused by consistent pressure on area

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24
Q

What are the causes of pressure sores?

A

Pressure sore causes:
* Sustained pressure on skin
* Friction
* Shearing force
* Increased temperature/moisture (sweating?)

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25
Q

How many stages are there of pressure sores?

A

There are 4 stages of pressure sores

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26
Q

What is the prevalence of pressure sores in hospitals?

A

Pressure sore prevalence
* Physical disability 85%
* Critically ill 33-53%,
* Orthopaedics 19-30%
* Hospitalized patients 3-23%,
*

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27
Q

What is the role of undernutrition pressure sore development?

A

Role of undernutrition pressure sore development
* Reduced nutrient supply> reduced energy metabolism> reduced maintenance and repair
* Increased weakness> reduced mobility> increased pressure
* Increased oedema> reduced tissue blood flow> ischaemia
* Weight loss> prominent bones> increased sensitivity to pressure

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28
Q

Can obese/overweight people be undernourished?

A

Yes. Obese or overweight people can be undernourished

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29
Q

What is sarcopenia?

A

Sarcopenia is defined as loss of muscle mass, strength and function.

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30
Q

How is undernutrition defined? (NICE 2006)

A

Undernutrition is defined by:
* >5% unintentional weight loss in 3 months
* > 10% unintentional weight loss in 3-6 months
* BMI < 20 kg/m2 + unintentional weight loss > 5% in 3-6 months

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31
Q

Should older people have lower or higher BMIs for survival?

A

Older people should have higher BMIs for optimal survival. (Cederholm 2015)

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32
Q

According to Stratton et al., 2003, BMI <18.5 kg/m2 is associated with?

A

According to Stratton et al., 2003, BMI <18.5 kg/m2 is associated with:
* Increased frequency of illness
* Reduced ability physical work capacity

33
Q

What are the characteristics associated with >5% weight loss?

A

Characteristics associated with >5% weight loss:
* Less energetic
* Reduced voluntary activity
*Fatigue

34
Q

What are the characteristics associated with >10% weight loss?

A

Characteristics associated with >10% weight loss
* Disturbances in thermoregulation
* Poor response to surgery and chemotherapy

35
Q

Is poor nutritional intake a part of the malnutrition defining process?

A

Poor nutritional intake is not part of the process for ‘defining’ malnutrition, but it can help to assess risk.

36
Q

What is refeeding syndrome?

A

Refeeding syndrome is the electrolyte/fluid shifts that occur following the introduction of nutrition in a malnourished individual. Electrolyte and fluids are imbalanced.

37
Q

Which electrolytes are affected in refeeding syndrome?

A

Phosphate, potassium and magnesium are affected in refeeding syndrome.

38
Q

According to WHO how many adults are undernourished worldwide?

A

According to WHO (2021) 462 million adults are undernourished worldwide.

39
Q

What is wasting?

A

Wasting: Low weight for height

40
Q

What is stunting?

A

Stunting: low height for age

41
Q

Various studies have found an increase in the frequency of illness amongst people with BMIs of ____

A

Various studies have found an increase in the frequency of illness amongst people with BMIs of less than 20 kg/m2

42
Q

If someone has a BMI of less than ____ malnutrition is considered probable

A

If someone has a BMI of less than 18.5 malnutrition is considered probable

43
Q

With a BMI of ____ malnutrition is possible with unintentional weight loss

A

With a BMI of 18.5-20 malnutrition is possible with unintentional weight loss

44
Q

BMI cut offs are higher with _______ _________

A

BMI cut offs are higher with weight loss

45
Q

Is nutritional intake a part of the malnutrition defining process?

A

No, nutritional intake is not a part of the malnutrition defining process. It helps to assess if someone is at risk.

46
Q

In relation to nutritional intake, when do we wonder if someone is likely to become malnourished?

A

NICE 2006: ‘where a patient ‘has eaten little or nothing for more than 5 days and/or is likely to eat little or nothing for the next 5 days or longer’

47
Q

Which vitamin may be deficient in refeeding syndrome?

A

Thiamine may be deficient in refeeding syndrome

48
Q

Describe the pathophysiology of Refeeding Syndrome

A

Refeeding syndrome pathophysiology
1. Starvation: Catabolism dominates: Glucagon secretion increased. Glycogen (glycogenolysis), protein degradation & fat (lipolysis/ beta oxidation). Increased gluconeogenesis.
2. Depletion of macronutrient stores, protein, minerals, electrolytes
3. . Refeeding (nutrition introduced)
4. . Insulin increased> anabolic pathways increase
5. . Increased: glucose uptake, electrolyte uptake, micronutrient utilization (thiamine), protein synthesis, glycogenesis.
6. Electrolytes and micronutrients utilized faster than they can be replaced> refeeding syndrome
7. . Severe deficiency: Hypokalaemia, Hypomagnesaemia, Hypophosphataemia, Thiamine deficiency, salt and water retention: Oedema
8. Imbalance of electrolytes: heart, nervous system and organ failure.

49
Q

What might hypokalaemia lead to?

A

Hypokalemia may lead to cardiac arrhythmias or weakness, fatigue, paralysis, hypoventilation, respiratory distress, and metabolic alkalosis

50
Q

What might hypophosphataemia lead to?

A

Hypophosphataemia may lead to: decreased cardiac contractility and arrhythmias. Increase haemoglobin’saffinity for oxygen> decrease oxygen release to the tissues; acuterespiratory failure.

51
Q

What might hypomagnesemia lead to?

A

Hypomagnesemia may lead to: exacerbated hypokalemia, neuromuscular symptoms and depression

52
Q

What might thiamine deficiency lead to?

A

Thiamine deficiency might lead to: lactate accumulation, Wernicke’s syndrome, Korsakoff syndrome and cardiac dysfunction.

53
Q

What are the consequences of starvation?

A

Consequences of starvation
* Decreased insulin and increased glucagon secretion
* Glycogen stores depleted
* Free fatty acids and ketones replace glucose as energy source (adipose tissue activated> fatty acids released)
* BMR decreases
* Brain adapts to using ketones
* Atrophy of all organs
* Reduced lean body mass
* Abnormal liver function
* Deficiency of vitamins and trace elements
* Whole body depletion of potassium, magnesium and phosphate
* Increased intracellular and whole body sodium and water
* Impaired cardiac, intestinal and renal reserve, leading to inability to excrete excess sodium and water
* Serum concentrations of electrolytes maintained within normal limits

54
Q

What are the 4 triggers of refeeding syndrome?

A

4 refeeding syndrome triggers:
1. A switch from fat to carbohydrate metabolism
2. Increased insulin release
3. Increased uptake of glucose, phosphate, potassium, magnesium and water into the cells
4. Synthesis of lean tissue

55
Q

What do the refeeding triggers lead to?

A

The refeeding triggers lead to:
1. Fluid retention
2. Low serum levels of potassium, magnesium, phosphate
3. Cardiac, respiratory, neuromuscular, renal, metabolic, hepatic and GI problems
4. Vitamin deficiency (thiamine)

56
Q

Low level of potassium

A

<3.2 mmol/L (Brown et al., 2015)

57
Q

What is Mg a co factor for?

A

Mg is a co factor for ATP

57
Q

___________ reverses negative nitrogen balance via suppression of gluconeogenesis and reduced amino acid usage

A

**Glucose **reverses negative nitrogen balance via suppression of gluconeogenesis and reduced amino acid usage

58
Q

What can excess glucose lead to?

A

Excess glucose can lead to:
Hyperglycaemia
Reduced sodium and water excretion
Increased cellular thiamine utilisation due to its role as a co-factor for carbohydrate metabolism

58
Q

NICE 2006 guidelines to recognise if someone is at risk of refeeding syndrome

A

NICE 2006 guidelines for refeeding syndrome risk:
At risk:
* Little or no food for >5days

High risk: 1 or more of the following:
* BMI < 16KG/M2
* Unintentional weight loss > 15% in 3-6months
* Little or no food for > 10 days
* Low K, Mg or Phosphate prior to feeding

** High risk:** 2 or more of the following:
* BMI <18.5 kg/m2
* Unintentional weight loss >10% in 3-6 months
* Little or no food >5 days
* History of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics.

Extremely high risk
* BMI < 14 kg m2
* Low or no food for > 15days

58
Q

What are the NICE 2006 refeeding guidelines for those “At risk”?

A

NICE 2006 refeeding guidelines for At Risk
* 50% of total energy requirements for the first 2 days,
* Full requirements of fluid, electrolytes, vitamins and minerals from day 1

59
Q

What are the NICE 2006 refeeding guidelines for those “High risk”?

A

NICE 2006 refeeding guidelines for High Risk
* 10kcal/kg increased slowly to meet requirements after 4-7 days
* Monitor fluid, K, P, Mg
* Give thiamine and multivitamin

60
Q

What did Baldwin & Weekes 2012 find when comparing dietary counselling with usual care and ONS?

A

Baldwin and Weekes 2012 found that comparing dietary counselling with usual care and with ONS, had no effect on mortality but did increase weight –mean 1.7 kg.

61
Q

What did Beck et al. 2014 find about the addition of a dietitian to the discharge team?

A

Beck et al., 2014 found that the addition of a dietitian to the discharge team reduced hospital admissions and increased oral intake.

62
Q

How much protein should elderly patients be having?

A

Elderly adults should have: Between 1.0 and 2.0 g/kg/day or higher (depending on health status e.g. severity of disease and risk of malnutrition) (ESPEN, 2019)

63
Q

What are the fluid requirements for 18-60 year olds?

A

18-60 year olds need 35 ml/kg

64
Q

What are the fluid requirements for >60 year olds?

A

> 60 year olds need 30ml/kg

65
Q

What are the other considerations for fluid requirements?

A

Other fluid requirement considerations:
* Add 2-2.5 ml/kg for each degree rise in temperature above 37
* Assess additional losses from wounds and diarrhoea individually

66
Q

Estimating energy requirements for adults

A
  1. Population: Age based EAR for BMI of 22.5. PAL:1.63 (SACN 2011)
  2. Therapeutic diets: BMR: PAL: (Henry 2005)
  3. Nutrition support: REE: PAL (PENG 2018)
67
Q

What has hand grip dynamometry been associated with for assessment?

A

Hand grip strength has been associated with assessment of:
* serum albumin
* sarcopenia
* malnutrition
* Nutritional status and disease severity in adults with cystic fibrosis
* Nutritional status in cancer

68
Q

What is sarcopenia?

A

The presence of low skeletal muscle mass and either low muscle strength (e.g., handgrip) or low muscle performance (e.g., walking speed or muscle power); when all three conditions are present, severe sarcopenia may be diagnosed.

69
Q

What are the 5 options for the Food Based Strategy?

A

Food based strategy*
1. Meal pattern e.g., regular meals
2. Snacks e.g., high energy + high protein snacks (flapjacks, custard, rice pudding)
3. Dietary advice to
- choose energy dense foods
- choose the best time to eat
- opt for nutritious drinks
- boost flavour and aroma of meals (especially with those who are consuming texture modified diets or have loss of taste and smell)
-consider meal delivery services
4. Food fortification
-adding extra calories to meals without increasing volume such as olive oil, cheese, cream, full-fat milk, skimmed milk powder, honey, jam and sugar.
5. Optimise appearance of foods (particular texture modified foods) use colourful plates to encourage food intake.

70
Q

What did Smoliner et al. 2008 find about food fortification?

A

Smoliner et al. 2008 found that food fortification can increase protein intake, hand grip strength was maintained but was not significant.

71
Q

What is used if the Food Based Strategy doesn’t work?

A

If the Food Based Strategy doesn’t work:
* Oral Nutrition Supplements
* Enteral nutrition
* Patenteral nutrition
* Tube feeding

72
Q

How many calories/protein will a tablespoon of dried milk powder add?

A

1 tablespoon of dried milk powder: 55 calories, 5.5g protein

73
Q

How many calories/protein will a tablespoon of ground almonds add?

A

1 tablespoon of ground almonds: 60 calories, 2g protein

74
Q

How many calories/protein will a tablespoon of grated cheese add?

A

1 tablespoon of grated cheese: 40 calories, 2.5g protein

75
Q

What did Mills et al. 2018 find about food fortification?

A

Mills et al., 2018 found that food fortification is: Effective, well‐tolerated and cost‐effective intervention to improve dietary intake amongst older inpatients

76
Q

Environment considerations for undernutrion

A

Environment considerations for undernutrion
* Social –number of people and better known will increase intake
* Encouragement
* Protected mealtimes
* Ambiance
* Timing

NHD (15 decks)

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