hospital setting

• Clinically relevant malnutrition


  The state of altered nutritional status that is associated with an increased risk of adverse clinical events such as complications or death

  
• Iatrogenic malnutrition


  Malnutrition due to various medications or some complications to medical treatment or procedure, possible causes: negligence among medical personnel including doctors, nurses, therapists, or caregivers who are attending to a particular patient

  
• Malnutrition


  A broad term that can be used to describe any imbalance in nutrition; from over-nutrition often seen in the developed world, to under-nutrition seen in many developing countries, but also in hospitals and residential care facilities in developed nations
• Cachexia


  A multifactorial syndrome characterized by severe body weight, fat and muscle loss and increased protein catabolism due to underlying disease(s)
• Sarcopenia


  Loss of muscle mass and function
• Malnutrition seen in hospitalised patients is often a combination of cachexia (disease-related) and malnutrition (inadequate consumption of nutrients) as opposed to malnutrition alone

  
• Malnutrition refers to the complex interplay between underlying disease, disease-related metabolic alterations and the reduced availability of nutrients (because of reduced intake, impaired absorption and/or increased losses or a combination of these) which is a combination of cachexia and malnutrition
• Causes of malnutrition

  • Deficiency in dietary intake
  • Increased requirements associated with a disease state
  • Complications of an underlying illness such as poor absorption and excessive nutrient losses
  • Combination of these factors
• Malnutrition is associated with negative outcomes for patients: higher infection and complication rates, increased muscle loss, impaired wound healing, longer length of hospital stay and increased morbidity and mortality, depression of the immune system, higher treatment costs
• Factors contributing to malnutrition in acute care patients

  • Personal: Age, Apathy/depression, Disease (e.g., cancer, diabetes, cardiac, gastrointestinal), Inability to buy, cook or consume food, Inability to chew or swallow, Limited mobility, Sensory loss (taste, smell), Treatment (ventilation, surgery, drain tubes), Drug therapy
  • Organisational: Failure to recognise malnutrition, Lack of nutritional screening or assessment, Lack of nutritional training, Confusion regarding nutritional responsibility, Failure to record height and weight, Failure to record patient intake, Lack of staff to assist with feeding, Importance of nutrition unrecognised

  
• Nutrition assessment


  A comprehensive approach to defining nutritional status using medical, nutritional, and medication histories; physical examination, anthropometric measurements and laboratory data
• Nutrition assessment is a diagnostic tool to determine if a patient is currently malnourished, though does require greater skill and time to perform than nutrition risk screening

  
• Objectives of nutrition assessment

  • To accurately define the nutritional status of patients
  • To define clinically relevant malnutrition
  • To monitor any changes in nutritional status during nutritional support
• Criteria when selecting tests for nutritional assessment of hospital patients

  • Precision
  • Sensitivity
  • Specificity
  • Predictive value of measurements
  • Sampling and statistical procedures
• Types of (nutritional assessment) tests

  • Tests that assess protein-energy malnutrition
  • Dietary
  • Anthropometric
  • Static biochemical
  • Functional indices of nutritional status
• Nutritional and metabolic parameters commonly measured in a full nutritional assessment

  • Anthropometric measurements: height, weight, usual weight, BMI, sex, IBW, weight as a percentage of IBW (%), weight as a percentage of usual weight (%), triceps skinfold, arm circumference, arm muscle circumference, triceps skinfold as a % of standard, arm muscle circumference as % of standard
  • Biochemical determination: serum albumin, total iron binding capacity, serum transferrin, lymphocyte count, white blood cell count, total lymphocyte count, 24-hour urinary nitrogen, 24-hour urinary creatinine, creatinine height index as % of standard
  • Diet and nutritional status: Protein intake, calorie intake, nitrogen balance, obligatory nitrogen loss, net protein utilization, basal energy expenditure (BEE), caloric intake of % of BEE, skin test results
• Subjective Global Assessment


  Most commonly used nutrition assessment tools, assesses nutrition status via completion of a questionnaire which includes data on weight change, dietary intake change, gastrointestinal symptoms, changes in functional capacity in relation to malnutrition as well as assessment of fat and muscle stores and the presence of edema and ascites, allows for malnutrition diagnosis, and classifies patients as either: A—well-nourished; B—mildly/moderately malnourished; or C—severely malnourished

  
• Factors included in Subjective Global Assessment

  • Weight: unintentional loss and time period of loss
  • Dietary intake: normal vs. decreased, type, duration, nutritional adequacy
  • GI symptoms for longer than two weeks: nausea, vomiting, diarrhea, anorexia
  • Functional capacity: working normally or suboptimally; ambulatory vs. bedridden
  • Disease state: degree of stress, metabolic demand
  • Physical signs: subcutaneous fat loss, muscle wasting, edema, ascites
• Mini Nutritional Assessment


  Developed to predict malnutrition in elderly (≥65 years) in hospitals, nursing homes and the community, 18 items divided into 4 components: anthropometric (weight, height, weight loss), general (lifestyle, medication, and mobility), dietary (number of meals, food and fluid intake autonomy of feeding), and subjective (self perception of health and nutrition), Short-form MNA (MNA-SF) provides a simple two-step nutrition screen, full MNA completed only for those patients deemed at nutritional risk

  
• Nutrition (risk) screening


  The process of identifying patients with characteristics commonly associated with nutritional problems who may require comprehensive nutrition assessment, a quick and simple evaluation that detects the risk of malnutrition and guides implementation of a clear action plan

  
• Nutrition screening can be performed by any trained health professional, but is usually completed by nursing or nutrition assistant staff
• Nutrition screening should occur within the first 24 -48 hours of admission
• Screening criteria


  • Usually weight and height, recent weight change, oral intake, and sometimes diagnosis and/or other comorbidities
• Screening is overlooked for some patients who have surgery within or soon after the first 24 hours of admission, so outpatient screening prior to surgical admissions may be beneficial
• Nutrition screening is routinely applied to high-risk patients to identify malnutrition and those who are at risk of becoming malnourished or who are malnourished

  
• Nutrition screening protocol


  • Simple, inexpensive, be completed by existing staff preferably on admission of the patient to the hospital
  • Identify malnutrition
  • Have the ability to anticipate nutritional depletion before malnutrition becomes clinically significant
• Examples of nutritional screening tools

  • Malnutrition Universal Screening Tool
  • Nutritional Risk Screening Tool 2002
  • Nutritional Risk Index
  • Mini Nutritional Assessment full and short forms (MNA and MNA-SF)

  
• Types of nutrition screening protocols

  • Screening using a single index (based on single anthropometric, biochemical, or functional parameters)
  • Multiparameter screening (based on aggregated measurements)
  • Prognostic value of multiparameter scoring systems
  • Based exclusively on clinical assessment
• Screening using a single index


  Screening with a single biochemical index (serum albumin is most widely used as a single screening index of nutritional status and predictor of outcome in sick hospital patients, low serum albumin is associated with a longer hospital status, reduced ability to return home, and increased mortality), Screening using anthropometry (simple, cheap, noninvasive, preadmission and preoperative weight loss are associated increases in postoperative operations, duration of hospital stay, post operative mortality), Screening using functional indices (nutritional depletion results in lowered physiological functional effects such as muscle weakness (hand grip strength), poor wound healing, impaired thermoregulation, depression, irritability, and fatigue, physiological functional impairment is likely to occur when <20% of body protein is lost)
• Multiparameter screening


  Also referred to as scoring systems, points-based scoring system to determine if a patient is at risk of, or suffering from, malnutrition, must be easy to use, cost effective, tested for reproducibility, validity, sensitivity, and specificity, no universally accepted multiparameter scoring system of nutritional status
• Prognostic Nutritional Index


  Calculated based on the serum albumin concentration and total lymphocyte count in the peripheral blood, originally proposed to assess the perioperative immune nutritional status and surgical risk in patients undergoing gastrointestinal surgery, developed to help clinicians decide when specialized nutrition therapy is required
• Nutritional Risk Index (Nutritional Risk Screening)


  Evaluates the efficacy of perioperative total parenteral nutrition in malnourished patients undergoing abdominal or thoracic surgery, recent weight loss, decreased BMI and reduced dietary intake, combined with a subjective assessment of disease severity (based on increased nutrition requirements and/or metabolic stress), subjective grading of illness severity and may not accurately reflect current nutritional status, tool does not allow for definitive diagnosis of malnutrition, has been recommended for use in hospitalised patients by ESPEN and may be useful for prompting the initiation of nutrition support

  
• Malnutrition Screening tool (MST)


  Simple, three-question tool assessing recent weight and appetite loss validated for use in general medical, surgical and oncology patients, designed for use by non-nutrition-trained staff, utilises a scoring system to identify patients at high nutrition risk which can then provide a basis for dietetic referrals and intervention

  
• Malnutrition Universal Screening Tool (MUST)


  Developed to detect both under-nutrition and obesity in adults, and was designed for use in multiple settings including hospitals and nursing homes, Body Mass Index (BMI), unplanned weight loss and the presence or absence of serious disease allow a score to be derived to indicate whether nutrition intervention is necessary, limited by the fact it has not been validated in children or renal patients

  
• Short Nutrition Assessment Questionnaire (SNAQ)


  Developed to diagnose malnutrition in hospitalised patients, provides an indication for dietetic referrals as well as outlining a nutrition treatment plan, it has been validated for hospital inpatient and outpatient use, as well as residential patients, does not require calculation of BMI