Malnutrition and Nutritional Assessment

Question 1

Define malnutrition

Answer 1

A state resulting from lack of uptake or intake of nutrition leading to altered body composition and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease

Question 2

Is malnutrition more common in men or women?

Answer 2

Women

Question 3

What age is malnutrition most common in?

Answer 3

Older people (over 65)
Also a bit in younger people

Question 4

In what patients is malnutrition more common?

Answer 4

Those with long standing or chronic progressive conditions

People who have used drugs/alcohol Gastroenterology patients

Question 5

Can malnutrition be put down to insufficient or poor quality food provided by hospitals?

Answer 5

No, most hospitals provide nutritional food but patients only intake average 40% of whats given to them (due to eg anorexia, GI symptoms, inactivity, depression, quality of food, belief that medical treatment is the main priority)

Question 6

Why is malnutrition bad?

Answer 6

There is physical and functional decline and poorer clinical outcomes including increased mortality, septic and post-surgical complications, length of hospital-stay, pressure sores, re-admissions, dependency

Question 7

What is the first step in diagnosing malnutrition?

Answer 7

Screen the patient via a screening too (bapen tool is used)

Question 8

After a patient has been screened for malnutrition if they are at risk whats the next step?

Answer 8

Assessment by a dietician involving anthropometry, biochemistry, clinical assessment, dietary assessment, social and physical factors, nutrition requirement

Question 9

What is anthropometry?

Answer 9

Measuring different compartments of the body

Question 10

What is useful for measuring body fat instead of BMI and why?

Answer 10

CT it can differentiate between muscle mass and fat while also differentiating visceral from subcutaneous fat

Question 11

In the dieticians assessment what is included in biochemistry? Are there any limitations?

Answer 11

Tests for nutrient availability in tissues

May be inaccurate due to inflammation so only do if CRP is below the threshold

Question 12

In the dieticians assessment what is included in clinical assessment?

Answer 12

Past history, signs, symptoms, medications

Question 13

In the dieticians assessment what is included in dietary?

Answer 13

Allergies, aversions, intolerances, cultural, religious, ethical, restriction

Question 14

In the dieticians assessment what is included in social and physical factors?

Answer 14

Can they access and afford food
Do they live and eat alone
Who cooks for them
Smoking, drug and alcohol addiction

Question 15

How is nutrition requirement calculated?

Answer 15

Equations are used

Question 16

What categories of patients show indications for nutrition support?

Answer 16

Malnourished

Those at risk of malnutrition

Question 17

What are the criteria for malnutrition?

Answer 17

BMI (< 18.5 kg/m2 )
Unintentional weight loss (>10 % past 3 - 6 / 12)
BMI (< 20 kg/m2 + unintentional weight loss > 5 % past 3 – 6 / 12)

Question 18

What are the criteria for being at risk of malnutrition?

Answer 18

Have eaten little or nothing for > 5 days and / or are likely to eat little or nothing for the next 5 days or longer
Have a poor absorptive capacity, and / or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism

Question 19

Define artificial nutrition

Answer 19

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

Question 20

What are the 2 routes for artificial nutrition?

Answer 20

Enteral nutrition (EN) Parenteral nutrition (PN)

Question 21

Which route of artificial nutrition is more ideal?

Answer 21

Enteral nutrition

Question 22

What method of artificial feeding is used if gastric feeding is possible?

Answer 22

Naso-gastric tube (NGT)

Question 23

What method of artificial feeding is used if gastric feeding is not possible?

Answer 23

Naso-duodenal (NDT) / naso-jejunal tube (NJT)

Question 24

What method of artificial feeding is used long term?

Answer 24

Gastrostomy/jejunstomy

Question 25

What are some complications of enteral feeding?

Answer 25

``` Mechanical= misplacement, blockage, buried bumper Metabolic= hyperglycaemia, deranged electrolytes GI= aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea ```

Question 26

Define parenteral feeding?

Answer 26

The delivery of nutrients, electrolytes and fluid directly into venous blood

Question 27

What are indications for parenteral feeding?

Answer 27

The delivery of nutrients, electrolytes and fluid directly into venous blood

Question 28

What are indications for parenteral feeding?

Answer 28

An inadequate or unsafe oral and/or enteral nutritional intake A non-functioning, inaccessible or perforated gastrointestinal tract

Question 29

What are the routes of access for parenteral feeding?

Answer 29

Central venous catheter (CVC): tip at superior vena cava and right atrium Different CVCs for short / long term use

Question 30

What are some complications of parenteral feeding?

Answer 30

Metabolic= deranged electrolytes, hyperglycaemia, abnormal liver enzymes, oedema, hypertriglyceridemia Mechanical= pneumo/haemothorax, thrombosis, arrhythmias, thrombus, catheter occlusion, extraversion Cather related infections

Question 31

Is nutrition support effective?

Answer 31

Yes, patients receiving support had significantly lower levels of mortality There was higher energy and protein intake, weight increase and less readmission to hospital, functional status

Question 32

How are albumin levels useful in relation to malnutrition?

Answer 32

Low plasma albumin = poor prognosis, as inflammation rises albumin synthesis falls

Question 33

Why do albumin synthesis levels fall when inflammation rises?

Answer 33

Inflammatory stimulus causes activation of monocytes and macrophages lading to cytokine release Cytokines act on the liver to stimulate production of some proteins whilst down regulating production of others like albumin

Question 34

Is albumin a valid marker of malnutrition?

Answer 34

Although synthesis falls in inflammation it’s not a good marker, some people may have low albumin despite being overweight due to trauma etc

Question 35

What is refeeding syndrome?

Answer 35

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

Question 36

In starvation what happens to insulin and glucagon levels?

Answer 36

Insulin falls | Glucagon rises

Question 37

In starvation what happens to water, sodium, potassium, magnesium, phosphate levels?

Answer 37

Increased extracellular water and sodium | Low potassium, magnesium and phospahte

Question 38

Why does refeeding syndrome arise?

Answer 38

Carbs reduce sodium and fluid excretion causing expansion of extracellular fluid leading to refeeding oedema

Question 39

What are some consequences of RFS?

Answer 39

Arrhythmia, tachycardia, CHF leading to cardiac arrest, sudden death Respiratory depression Encephalopathy, coma, seizures, rhabdomyolysis, Wernicke’s encephalopathy

Question 40

What are the categories for RFS?

Answer 40

At risk High risk Extremely high risk

Question 41

Briefly describe how is RFS managed?

Answer 41

Start with very low calorie intake and micronutrients from onset Correct and monitor electrolytes daily Administer thiamine from onset Monitor fluid shifts and minimise risk of fluid or sodium overload