T1 L12: Malnutrition

• What is malnutrition according to NICE guidelines?

  a state in which a deficiency of nutrients such as energy, protein, vitamins and minerals

  causes measurable adverse effects

  on body composition, function or clinical outcome.
• Malnutrition also includes overnutrition.
• Why is increased prevalence of obesity in children alarming?

  obesity in children has an effect on their epigenetics

  more difficult to treat in adulthood
• How is the worlwide prevalence of obesity changed?

  nearly tripled between 1975-2016
• How have childhood and adolescent obesity rates changed in the last 4 decades?

  tenfold increase
• Hospital patients are an ageing population.

  
• How is the prevalence of malnutrition on admission to hospital like?

  most likely individuals on hospital settings to be malnourished are elderly patients

  both ends of the spectrum are usually patients with chronic illness, so more likely to be malnourished

  
• How does the malnutrition risk change according to the type of hospital ward?

  oncology ward highest

  care of elderly/stroke second highest

  
• How does prevalence of malnutrition vary in relation to underlying disease?

  highest in GI disease

  respiratory second highest

  
• How does prevalence of malnutrition vary in surgical patients?

  most prevalent in patients undergoing general surgery

  then GI surgery

  followed by cancer surgery

  and major vascular surgery

  
• What are the possible mechanisms of malnutrition?

  Inadequate nutrient intake

  impaired nutrient digestion and processing (dysfunction in GI organs)

  excess losses

  altered requirements (when the metabolic machine itself is different)
• What are possible 'excess losses' that may cause malnutrition?

  vomiting, NG tube drainage, diarrhoea, surgical drains, fistulae, stomas, large area burns
• What are some examples of 'altered requirements' that may cause malnutrition?

  increased metabolic demands such as:

  • inflammation
  • cancer
  • wounds
  • burns
  • brain injury
• What is anorexia?

  absence of appetite
• What is the primary source of energy during uncomplicated fasting (12-24 hours)?

  glucose
• What is the primary source of energy during uncomplicated fasting (7 days)?

  ketone bodies
• What is the difference between 'simple' starvation and 'stress' starvation?

  simple refers to 'not complicated by disease process' (physiological mechanism)

  stress refers to pathological
• What is the primary source of energy during stress starvation?

  gluconeogenesis (primarily amino acids)
• What are the metabolic changes in simple starvation?

  • metabolic rate: decreases
  • muscle protein breakdown: increases
  • protein synthesis: decreases
  • plasma albumin: +/- same
  • nitrogen balance: decreases
  • ketone bodies: increases massively
  • gluconeogenesis: increases
  • blood glucose: decreases
  • insulin plasma conc: increases
  • insulin resistance: increases
  • salt & water retention: increases
• What are the metabolic changes in stress starvation?

  • metabolic rate: increases
  • muscle protein breakdown: increases massively
  • protein synthesis: increases
  • plasma albumin: decreases significantly
  • nitrogen balance: decreases significantly
  • ketone bodies: increases
  • gluconeogenesis: increases significantly
  • blood glucose: increases
  • insulin plasma conc: increases
  • insulin resistance: increases
  • salt & water retention: inreases massively
• Why does plasma albumin level decrease significantly in stress starvation?

  albumin leaks through leaky capillary beds due to inflammation
• Why does protein synthesis increase in stress starvation?

  due to production of inflammatory mediators
• Why does plasma albumin remain more or less the same during simple starvation?

  because plasma albumin is not related to nutrition
• What are the impacts of malnutrition in healthy people?

  decreased skeletal muscle mass and function by day 5

  +18% loss of mass leads to physiological disturbance:

  • reduction in cardiac output
  • reduction in respiratory/diaphragmatic muscle mass and contractility
  • impaired gut and immune function

  approximately 40% weight loss is fatal
• What is the malnutrition carousel?

  Cycle of malnutrition leading to poor health outcomes

  1. 25-34% of hospital admissions are at risk of malnutrition
  2. Longer stay, more complications; more support needed after discharge from hospital; more likely to need care
  3. 70% of patients weigh less on hospital discharge
  4. More GP visits; more prescriptions; more hospital admissions

  
• What does malnutrition cost to the NHS?

  health costs exceeding GBP 19.6 billion annually

  identifying and treating malnutrition presents the fourth biggest potential saving in the NHS today
• What is one reason why malnutrition gets worse during a hospital stay according to the 2008 study?

  nutrition is not looked after / recorded as much as it should be
• How do hospitals cause malnutrition?

  • inadequate / unplatable / unsuitable food
  • can't reach food / can't feed themselves
  • altered taste / poor appetite
  • NBM (nothing by mouth, eg before surgical procedures)
  • Starved for Ix
  • and then again if Ix gets cancelled
• What is dysphagia?

  inability to swallow correctly
• What are the environmental causes of malnutrition in hospitals?

  • inadequate food quality
  • inadequate food availability (outside the reach of elderly / physically incapacitated patients)
  • no protected meal times
  • inadequate training and knowledge of medical and nursing staff
• How can hospital malnutrition be prevented?

  find patients 'at risk': screening

  be on the look out for:

  • low weight
  • weight loss
  • poor intake or predicted to become poor (ie planned surgery)
  • poor absorptive capacity
  • high nutrient losses
  • increased nutritional needs (burns, sepsis etc)
• What are some measurements for nutrition/size/body (anthropometry)?

  BMI (body mass index), MUAC (mid upper arm circumference), ulna length
• What is the MUST screening tool?

  Malnutrition universal screening tool (as per prescription)

  takes into account BMI, unplanned weight loss, acute illness

  gives overall risk of malnutrition

  
• What are the courses of action taken following a MUST screening?

  low risk: routine clinical care

  medium risk: observe, keep screening

  high risk: refer to dietician

  
• What has been done so far to address the problem of hospital malnutrition?

  Nutrition screening, education, and personalized nutrition plans.