Malnutrition and Nutrition Intervention in the Hospitalised Adult

Question 1

define malnutrition

Answer 1

A state in which deficiency, excess or imbalance, of energy, protein or other nutrients, results in a measurable adverse effect on body composition, function and clinical outcome

Question 2

what percentage of patients will have lost weight on discharge?

Answer 2

70% - mainly loss of muscle mass

Question 3

what factors increase risk of malnutrition in hospital?

Answer 3

disease related anorexia
metabolic response to injury/ illness
repeated NBM status
quality of food
GI symptoms
inflexibility of mealtimes
inactivity
low mood and depression
poly-pharmacy
co-morbidities

Question 4

what are some of the impacts of malnutrition?

Answer 4

physical and functional decline and poorer clinical outcomes.
increased mortality, septic and post surgical complications.

Question 5

what are the two different indications for nutrition support?

Answer 5

Nutrition support should be considered in people who are either:

1. Malnourished =
   BMI < 18.5 kg/m2 or
   Unintentional weight loss >10 % past 3 - 6 / 12 or
   BMI < 20 kg/m2 + unintentional weight loss > 5 % past 3 – 6 / 12.
   2.At risk of malnutrition =
   Have eaten little or nothing for > 5 days and / or are likely to eat little or nothing for the next 5 days or longer or
   Have a poor absorptive capacity, and / or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism.

Question 6

what three steps are involved in the diagnosis of malnutrition?

Answer 6

screen - MUST tool
assessment via a dietician - based on: anthropometry, biochemistry, clinical history, diet history, social and physical, nutrition requirements
diagnose

Question 7

what is anthropometry

Answer 7

measurement system of the size and makeup of the body - weight, BMI, muscle mass, mid upper arm circumference, triceps skin fold thickness, CT for muscle composition and subcutaneous and visceral fat

Question 8

What is biochemistry used for in malnutrition?

Answer 8

To see nutrient availability

Question 9

What are some of the disadvantages to using biochemistry in malnutrition?

Answer 9

Can be expensive for micronutrients CRP below 10
Can be skewed due to inflammation - wait until

Question 10

What is the most reliable way to measure energy expenditure?

Answer 10

Indirect calorimetry

Question 11

What is indirect calorimetry?

Answer 11

Resting metabolic rate measurement using respirator gas exchange canopy
Can use predictive equations to find estimates too

Question 12

What are the nutritional options available via the oral route?

Answer 12

Fortification of meals and snacks
•Altered meal patterns
•Practical support
•Oral nutritional supplements (ONS)
•Tailored dietary counselling

Question 13

When should oral nutrition support be considered?

Answer 13

onsider for any patient with inadequate food and fluid intakes to meet requirements, unless they cannot swallow safely, have inadequate gastrointestinal function or if no benefit is anticipated e.g. end of life care.

Question 14

What is artificial nutrition support?

Answer 14

The provision of enteral or parenteral nutrients to treat or prevent malnutrition

Question 15

Where parenteral nutrition is used, what is the overall aim?

Answer 15

To return to enteral -> oral feeding as soon as clinically possible

Question 16

What is enteral nutrition?
What is parenteral nutrition?

Answer 16

Enteral = tube feeding
Parenteral = delivery of nutrients, electrolytes and fluid directly into venous blood.

Question 17

In enteral nutrition what are the two methods used and what are there uses based on?

Answer 17

Access:
Is gastric feeding possible?

•Yes = Naso-gastric tube (NGT)
•No = Naso-duodenal (NDT) / naso-jejunal tube (NJT)

Question 18

If a patient has been on enteral feeding for 3+ months, what should they be switched to?

Answer 18

Gastrostomy/ Jejunstomy

Question 19

Why would you choose to give enteral nutrition through NJT instead of a nasogastric tube?

Answer 19

NGT may be contraindicated in gastric outlet obstruction

Question 20

What complications are associated with enteral feeding?

Answer 20

Mechanical: misplacement, blockage, buried bumper

•Metabolic: hypergylcaemia, deranged electrolytes

•GI: Aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea.

Question 21

What are the indications for parenteral support?

Answer 21

Indications:

•An inadequate or unsafe oral and/or enteral nutritional intake

OR

•A non-functioning, inaccessible or perforated gastrointestinal tract

Question 22

What is the access point for parenteral nutrition support?

Answer 22

Central venous catheter (CVC): tip at superior vena cava and right atrium.

•Different CVCs for short / long term use.

Question 23

Q. What are the complications associated with parenteral nutrition?

Answer 23

Metabolic: deranged electrolytes, hyperglycaemia, abnormal liver enzymes, oedema, hypertriglyceridaemia
Catheter related infections
Mechanical: pneumothorax, haemothorax, thrombosis, cardiac arrhythmias, thrombus, catheter occlusion, thrombophlebitis, extravasion

Question 24

What does hypoalbuminaemia in malnutrition indicate?

Answer 24

A poor prognosis

Question 25

Where is albumin synthesised?

Answer 25

Liver

Question 26

How does the acute phase response alter serum albumin?

Answer 26

The acute phase response.
•Inflammatory stimulus → activation of monocytes & macrophages → release cytokines.
•Cytokines act on liver to stimulate synthesis of some proteins e.g. c-reactive protein, whilst downregulating production of others e.g. albumin.
Degradation and transcapillary loss of albumin increase in inflammatory state

Question 27

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

Answer 27

No

Question 28

What is refeeding syndrome?

Answer 28

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

Question 29

What are the consequences of refeeding syndrome?

Answer 29

Consequences of RFS:
•Arrhythmia, tachycardia, CHF → Cardiac arrest, sudden death
•Respiratory depression
•Encephalopathy, coma, seizures, rhabdomyolysis,
•Wernicke’s encephalopy

Question 30

Outline the pathology of refeeding syndrome

Answer 30

During starvation the body aims to utilise energy stores - metabolism switches from carbohydrate to fat, insulin secretion decreases and glucagon increases.
Action of cellular pumps are reduced
Depletion in K+, phosphate and MG2+
Then in refeeding insulin secretion increases in response to blood sugar, increased basal metabolic rate and synthesis which requires phosphates, K+ and Mg2+ which don’t have causing electrolyte and thiamine levels to fall

Question 31

What categories someone as been at risk of RFS according to NICE guidelines?

Answer 31

Very little or no food intake > 5daysb

Question 32

According to NICE guidelines, what classes someone as being high risk of RFS?

Answer 32

High risk:
1 of the following:
•BMI < 16 kg/m2
•Unintentional weight loss > 15 % 3 – 6 /12
•Very little / no nutrition > 10 days
•Low K+, Mg2+, PO4 prior to feeding

Or 2 of the following:
•BMI < 18.5 kg/m2
•Unintentional weight loss > 10 % 3 – 6 / 12
•Very little / no nutrition > 5 days
•PMHx alcohol abuse or drugs (insulin, chemotherapy, antacids, diuretics)

Question 33

According to NICE guidelines what criteria is needed for someone to be classed as extremely high risk of RFS?

Answer 33

BMI < 14
Negligible intake > 15days

Question 34

What is the management plan for RFS?

Answer 34

Start with no more than 10-20 kcal/kg nutrition
40-50% from CHO
Micronutrients given from onset
Correct and monitor electrolytes daily
Thiamine administered from onset of feeding
Monitor fluid shifts and minimise risk of fluid or sodium overload