nutrition in practice

Question 1

define malnutrition

Answer 1

a state of nutrition in which a deficiency or excess of energy, protein and other nutrients causes measurable adverse effects on tissue / body form and function and clinical outcome.

Question 2

what % of patients are malnourished on hospital admission?

Answer 2

40%

Question 3

what is the annual cost of malnutrition to NHS England?

Answer 3

19.6 billion

Question 4

what are the causes of malnutrition?

Answer 4

intake < requirements bc;

• decreased intake when food is available
• decreased intake due to inadequate availability, quality or presentation of food
• increased nutritional requirement
• lack of recognition and treatment

Question 5

what can cause decreased intake of food?

Answer 5

Dysphagia
Prolonged periods NBM
Side effects of treatment
Pain/constipation
Psychological e.g. depression
Social e.g. low income, isolation
Poor dentition
Reflux/feeding problems/food intolerance's

Question 6

what can cause increased requirement of food?

Answer 6

Infections
Involuntary movements
Wound healing

Question 7

what can cause increase loss of nutrition?

Answer 7

Malabsorption from gut
Diarrhoea and vomiting
High stoma output

Question 8

what are the consequences of malnutrition?

Answer 8

Decreased respiratory function
Decreased cardiac function
Decreased Mobility
Increased risk of pressure sores
Increased risk of infection
Decreased wound healing
Increased risk of malabsorption
Apathy and depression

Question 9

what is the function of nutritional screening?

Answer 9

identifying malnutrition/risk of malnutrition

Question 10

when should nutritional screening be done?

Answer 10

on admission of all adult patients into hospital and then weekly thereafter

Question 11

what are the 2 main nutritional screening tools?

Answer 11

MUST (malnutrition universal screening tool)

STAMP (Screening Tool for the Assessment of Malnutrition in Paediatrics)

Question 12

what are the 5 steps of MUST?

Answer 12

1 - BMI
2 - weight loss
3 - acute disease effect
4 - add scores for steps 1-3
5 - action plan
repeat weekly

Question 13

what are the next steps for a patient with a MUST score of 0?

Answer 13

just need monitoring and to repeat the score weekly

Question 14

what are the next steps for a patient with a MUST score of 1?

Answer 14

observations (how much are the eating and drinking, are they finishing meals?)

Question 15

what are the next steps for a patient with a MUST score of 2 or more?

Answer 15

refer to a dietician who will suggest a form of nutrition to help the patient

Question 16

in what people can malnutrition be missed?

Answer 16

overweight patients

Question 17

how do you calculate BMI?

Answer 17

weight/height^2

Question 18

what are the ranges for BMI?

Answer 18

<19 - underweight
20-25 - normal
>25 - overweight

Question 19

what are surrogate measures of height?

Answer 19

Knee height
Demispan
Ulna length

Question 20

what is the problem with using surrogate measures?

Answer 20

may overestimate height

-underestimate BMI

Question 21

what are surrogate measures for weight?

Answer 21

Can measure in supine position
Obtain height or surrogate height
Can then estimate weight from BMI
(Weight (kg) = BMI x Height (m2)

Question 22

what is the BMI likely to be if MUAC is <23.5?

Answer 22

<20 (underweight)

Question 23

what is the BMI likely to be if MUAC is >32

Answer 23

> 30 (overweight)

Question 24

what are anthropometrics?

Answer 24

weight - dry/oedema/ascites
height
BMI
weight history
other measurements e.g. MUAC

Question 25

how much increase in body weight is needed before visual oedema can be seen?

Answer 25

increase of at least 1kg

Question 26

how can fat mass be measured?

Answer 26

Skinfolds (SF) Indirectly estimate total adiposity Commonly use triceps site (TSF)

Question 27

what does handgrip dynamometry/grip strength measure?

Answer 27

measures muscle strength and endurance

Question 28

what is albumin?

Answer 28

Large protein synthesised in the liver | Most abundant protein found in plasma and is usually trapped within capillaries

Question 29

what is the normal range of albumin in the body?

Answer 29

35-50g/L

Question 30

what is the function of albumin?

Answer 30

Maintains oncotic pressure | i.e. albumin molecules have an osmotic effect that helps to stop water leaking out through capillary walls

Question 31

what are the causes of hypoalbuminaemia?

Answer 31

- inadequate protein intake - in hospital: inflammation and sepsis associated with infection. capillary walls become more porous and albumin drifts out --> low plasma albumin

Question 32

who does low albumin occur in?

Answer 32

sick patients with infection increased CRP those with poor nutrition

Question 33

define refeeding syndrome

Answer 33

A potentially fatal condition characterized by severe fluid and electrolyte shifts and related metabolic implications in malnourished patients undergoing refeeding (via the oral, enteral or parenteral routes)

Question 34

what happens to the body in starvation?

Answer 34

Glucagon levels rises Insulin levels fall Glycogen used up in the first 24-72 hrs of starvation Shifts to protein for energy Fatty acids are metabolised to produce ketone bodies – become the major source of energy Loss of fat and lean body mass, water and minerals. Intracellular stores of K+, P04-, Mg2 become depleted

Question 35

what happens to the body in refeeding?

Answer 35

Metabolism changes from fatty acids to carbohydrates Raised insulin secretion Insulin stimulates K+, P04-, Mg2+ to return to cells ∴ intracellular stores are replenished but at the expense of plasma concentrations.

Question 36

what are the clinical consequences of refeeding syndrome?

Answer 36

hypophosphataemia hypomagnesaemia hypokalaemia

Question 37

what are the effects on the different body systems of hypophosphataemia?

Answer 37

Neurological—Seizures, paraesthesia Musculoskeletal—Rhabdomyolysis, weakness, osteomalacia Respiratory—Impaired respiratory muscle function Cardiac—Cardiac failure Renal—Rhabdomyolysis, fluid and salt retention

Question 38

what are the effects on the different body systems of hypomagnesaemia?

Answer 38

Neurological—Tetany, paraesthesia, seizures, ataxia, tremor Cardiac—Arrhythmias Gastrointestinal—Anorexia, abdominal pain

Question 39

what are the effects on the different body systems of hypokalaemia?

Answer 39

``` Neurological—Paralysis, paraesthesia Musculoskeletal—Rhabdomyolysis Respiratory—Respiratory depression Cardiac—Arrhythmias, cardiac arrest Gastrointestinal—Constipation, paralytic ileus ```

Question 40

who is at risk of refeeding syndrome?

Answer 40

any patient with very little food intake for >5 days

Question 41

who is at high risk of refeeding syndrome?

Answer 41

Any one the following; BMI <16 Unintentional weight loss >15% in last 3-6 months Little or no nutritional intake for more than 10 days Low levels of K, PO, Mg prior to feeding OR Any 2 of the following BMI <18.5 Unintentional weight loss >10% in last 3-6 months Little or no nutrition for more than 5 days A history of alcohol abuse or drug use including chemotherapy, antacids or diuretics

Question 42

why provide nutrition support?

Answer 42

Increased nutritional requirements are associated with the metabolic response to stress/trauma/sepsis Maintain nutritional status and limit catabolism Preserve lean body mass (LBM) Maintain immune function Preserve organ function and promote wound healing Enhance recovery and improve patient outcomes

Question 43

what are the routes for nutritional support?

Answer 43

enteral: oral, nasogastric, orogastric, nasojejunal, gastrostomy, jejunostomy paranteral: peripheral and central

Question 44

what type of oral nutritional support can you get?

Answer 44

supplement drinks

Question 45

what type of supplement drinks are available?

Answer 45

milkshake style - calorie content varies. ready-made juice based - fat free powdered - not nutritionally complete and the patient may not be able to mix it

Question 46

what nutritional supplements are given in dysphagia?

Answer 46

``` Pre-thickened drinks Thickening of supplement drinks with a thickener Yoghurt style drinks Smoothie style drinks Yoghurt/dessert pot type supplements ```