GI Malnutrition and nutritional assessment

Question 1

definition of malnutrition

Answer 1

state resulting from lack of uptake/intake of nutrition leading to diminished physical and mental function and impaired clinical outcome from disease

Question 2

rate of malnourishment upon admission to hospital

Answer 2

1 in 3 are manourished

Question 3

what % of patients have lost weight at discharge

Answer 3

70%

Question 4

factors that lead to malnutrition in hospitals

Answer 4

co-morbidities e.g. dementia
inflexible mealtimes
quality of food
dysphagia, stomatitis, anaemia, poor dentition, ill fitting dentures
inactivity
low mood/depression
polypharmacy
excess nutritional losses
repeated NBM status
metabolic response to disease/injury

Question 5

What is the relationship between post-op mortality and weightloss?

Answer 5

loss of >/=20% % of bodyweight preoperatively leads to 10x greater postop mortality

Question 6

what increases with malnutrition?

Answer 6

mortality
septic and post surgical complications
length of hospital stay
pressure sores
readmissions
dependency

Question 7

what decreases with malnutrition?

Answer 7

wound healing
response to treatment
rehabilitation
QoL

Question 8

what is the cost of malnutrition in England per year.

Answer 8

£19.6 billion -> likely to rise with ageing population

Question 9

CT good points formal nutrition assessment

Answer 9

provide info about body composition

-> however involves exposing patient to radiation

Question 10

Why is BMI not used to assess malnutrition?

Answer 10

not representative of difference between fat and fat free mass

Question 11

skin fold thicknesses used for malnutrition assessment

Answer 11

• triceps skinfold thickness

- mid upper arm circumference use similarly to determine lean body mass (positive association)

Question 12

anthropometric analysis multifrequency bioelectrical impedance analysis used in which patients?

Answer 12

renal and haematology patients

Question 13

what type of fat can CT scans distinguish between?

Answer 13

visceral and subcutaneous fat

-> highly accurate for evaluating levels of fat and fat free mass

Question 14

problems with CT

Answer 14

spenny and expose individuals to small amounts of radiation

• > use for body comp restricted to research normally
• > being used more frequently in specialities where CTs are already part of the clinical treatment pathway

Question 15

when is CT useful for patients with pancreatic cancer?

Answer 15

in patients which borderline resectable pancreatic cancer -> helps to determine sarcopenia prevalence

Question 16

what does hand grip respond to quickly?

Answer 16

• nutritional deprivation and nutritional repletion (more so that other parameters like muscle mass/body mass)

Question 17

why are micronutrient and trace elements tests not undertaken easily?

Answer 17

time consuming
spenny
-> results skewed as a result of the acute inflammatory response

Question 18

best way of obtaining dietary intake information?

Answer 18

dietary history

Question 19

what is used to estimate energy requirement,

Answer 19

predictive equations estimating resting BMR

-> generally no more accurate than 70%

Question 20

requirements to be malnourised

Answer 20

• BMI < 18.5
• unintentional weight loss >10% past 3-6 months
• BMI <20 + unintentional weight loss > 5% past 3-6 months

Question 21

at risk of malnutrition (2)

Answer 21

eaten little/nothing > 5 days and likely to have the same for the next 5
- poor absorptive capacity/high nutrient losses/increased nutritional needs

Question 22

what is the provision of enteral or parenteral nutrients to treat or prevent malnutrition called?

Answer 22

artificial nutrition support

Question 23

Feeding options when oral nutrition isn’t safe

Answer 23

1. enteral feeding (GI tract functional + accessible)

2. parenteral feeding (GI tract not functional/accessible)

Question 24

why is enteral nutritional superior to parentral?

Answer 24

it uses the gut

-> if parenteral used, aim to return to enteral then oral feeding as soon as/where clinically possible

Question 25

first line route for enteral nutrition?

Answer 25

nasogastric tube

Question 26

example of when NGT is contraindicated?

Answer 26

gastric outlet obstruction | -> NJT used instead

Question 27

what is recommended for longer term enteral tube feeding? | When is long term enteral tube given?

Answer 27

>3 months gastrostomy/jejunostomy | long term enteral tube given >4 wks

Question 28

what are the complications associated with enteral feeding?

Answer 28

- misplaced NGTs caused 21 deaths + 79 cases of harm from 2005-2011 - mechanical (misplacement, blockage, buried bumper) - metabolic (hyperglycaemia), deranged electrolytes) - GI aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea

Question 29

What should you do if there's a misplaced NGT?

Answer 29

aspirate of pH <=5.5 | - if pH> 5.5, CXR which is interpreted by professional following NPSA guidelines

Question 30

indication for parenteral nutrition

Answer 30

- inadequate or unsafe oral and/or enteral nutritional intake OR - non-functioning, inaccessible or perforated GI tract

Question 31

what type of nutrition is described as delivery of nutrients, electrolytes and fluid directly into venous blood?

Answer 31

parenteral nutrition

Question 32

access points for CVCs?

Answer 32

tip at superior vena cava and right atrium-> different CVCs for short ad long term use

Question 33

complications associated with parenteral nutrition?

Answer 33

mechanical (pneumothorax, haemothorax, cardiac arrhythmias, thrombosis, catheter occlusion, extravasion) metabolic (deranged electrolytes, hyperglycaemia, abnormal liver, enzymes, oedema, hypertriglyceridemia) catheter-related infection

Question 34

why is nutrition support offered to malnourished patients?

Answer 34

lower levels of mortality, readmission, ICU admission, major complications and functional status

Question 35

low levels of what plasma proteins predicts poor prognosis?

Answer 35

albumin

Question 36

how does the acute phase response affect albumin production?

Answer 36

inflammatory stimulus -> activation of monocytes and macrophages -> release of cytokines cytokines act on the liver to stimulate production of some proteins whilst downregulating production of others like albumin

Question 37

is albumin a valid marker of malnutrition in the acute hospital setting?

Answer 37

no - though decreased in repsonse to inflammation, not marker of nutrition status nor indication for nutrition intervention in the acute setting - best evidence - hypoalbuminaemia in obese trauma patients - dietitian focused on the etiology/impact of the inflammatory state on nutrition status

Question 38

what is refeeding syndrome?

Answer 38

a group of biochemical shifts and clinical symptoms that can occur in the malnourished/starved individual on the reintroduction of oral, enteral or parenteral nutrition

Question 39

stages of body response to starvation

Answer 39

1. body aims to utilize energy stores - reduction insulin secretion and increased in glucagon to increase glucose - glycogen stores in liver and AA in skeletal muscle metabolised -> glucose - stores depleted (within 24/72 hours) leads to derivation of energy from ketone production due to free fatty acids released from fat stores (used instead of AA to spare skeletal muscle) 2. decreased BMR and brain uses ketone bodies instead of glucose -> loss of fat mass - action cellular pumps reduced (to save energy) so electrolytes leak across cell membrane - increased extracellular water, Na and total body water and depletion of Mg, K and phosphate. - Serum electrolyte conc. maintained whilst intracellular stores are depleted - Na and fluid leak into cells -> sodium and fluid intolerance - micronutrients depleted - thiamine deficiency likely- water soluble and body has limited stores

Question 40

how does introduction of carbohydrate affect the response to starvation?

Answer 40

stimulates insulin production -> Na/K ATPase working - > Mg is a cofactor - > drives K into cells and Na out of cells - > carbohydrate and insulin drives PO4 into cells - increased cellular uptake of glucose, K, Mg and phosphate (hypokalaemia, hypophosphatemia, hypomagnesaemia) - thiamine is coenzyme for carb digestion -> deficiency occur in refeeding of vit B depleted patient

Question 41

what can low concentrations of electrolytes from giving a starving person carbs cause?

Answer 41

- less Na and fluid excretion = expansion extracellular fluid compartment --> this leads to refeeding oedema and fluid overload

Question 42

consequences of RFS?

Answer 42

- arrhythmia - CHF -> cardiac arrest + sudden death - tachycardia - respiratory depression - encephalopathy, coma, seizures, rhabdomyolysis - Wernickes encephalopathy

Question 43

According to NICE, what are the the criteria for defining at risk of refeeding syndrome/

Answer 43

very little or no food intake for > 5 days

Question 44

According to NICE, what are the the criteria for defining at high risk of refeeding syndrome/

Answer 44

``` >=1 of these: - BMI < 16 - unintentional weight loss > 15% 3-6/12 - very little/no nutrition > 10 days - Low K+, Mg2+, PO4 prior to feeding >=2 of these: - BMI < 18.5 - unintentional weight loss > 10% 3-6/12 - very little/no nutrition > 5 days - PMHx alcohol abuse or drug (insulin, chemo, antacids, diuretics) ```

Question 45

According to NICE, what are the the criteria for defining at extremely high risk of refeeding syndrome/

Answer 45

- BMI < 14 | - Negligible intake > 15 days

Question 46

stages of RFS management

Answer 46

1. start with 10/20kcal/kg 40-50% energy from carbs Micronutrients given from onset of feeding 2. correct + monitor electrolytes daily following trust policy 3. Administer thiamine 30 min from the onset of feeding following Trust policy 4. Monitor fluid shifts + minimise risk of fluids + Na overload

Question 47

Who is at highest risk of malnutrition?

Answer 47

``` >65 Long-term condition e.g. diabetes Chronic progressive disease GI dysfunction Drug abuse ```

Question 48

Which wards have highest rates of malnutrition?

Answer 48

Care of Elderly | Oncology

Question 49

In which ages is malnutrition highest in?

Answer 49

In order of most to least: 90+ 80-89 18-19

Question 50

What is the cost of malnourished patients in healthcare?

Answer 50

Cost is 3x greater

Question 51

When asking about dietary history, what do we have to ask about?

Answer 51

Allergies Intolerances Aversions Cultural, religious, ethical dietary restrictions

Question 52

What are different ways a dietician asses nutrition?

Answer 52

Anthropometry: Weight, tricep skinfold thickness, CT, hand grip Biochemistry Clinical: signs, PHx, symptoms, medications Dietary Social and physical assessment Nutrition requirements: indirect calorimetry

Question 53

What are pros and cons of biochemistry investigation is assessing nutrition?

Answer 53

Expensive and time-consuming | Shows inflammatory response

Question 54

What tube would we use for short term enteral feeding (2-4wks)?

Answer 54

Fine bore naso-enteral tube

Question 55

For a malnourished patient where oral nutrition is possible what are treatment options?

Answer 55

Oral nutritional support: counselling, supplements, dietary fortification Require texture modification- consider thickeners and additional support (oral tube)

Question 56

What kind of nutritional feeds are there?

Answer 56

``` Renal Low sodium Respiratory Immune Elemental Peptide ```