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Malnutrition when, where, and how

front 1

Define Malnutrition (2005)

back 1

a state of nutrition in which a deficiency or excess (imbalance) of energy, protein or other nutrients causes measurable adverse effects on tissue or body functions and clinical outcomes

front 2

Define Malnutrition (2017)

back 2

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

front 3

What are the two major pathophysiological pathways of malnutrition?

back 3

  • Starvation or deficiency-related Pathway

Initiated by decreased intake or absorption of food and nutrients

  • The inflammation/disease related pathway

Resulted from anoroxia and increased tissue breakdown

front 4

How does the body adapt to energy or nutrient deficiency?

back 4

  1. ⬇️ resting energy expenditure
  2. ⬇️ heart rate
  3. ⬇️ body temperature
  4. ⬇️ spontaneous physical activity
  5. Glycogen stores are depleted within 1 to 2 days
  6. Body fat is the main energy source
  7. Protein stores are partially protected, but muscle is still depleted to ensure a supply of amino acids for protein synthesis and oxidation for energy (to survive starvation)

front 5

Historical observations indicate that survival for up to ............ in a state of complete starvation is possible if fluids are available

back 5

60 days

front 6

How does the body adapt to inflammation-driven disease-related malnutrition?

back 6

  1. more complex and maladaptive
  2. ⬆️ REE increases
  3. ⬆️ resting heart rate
  4. ⬆️ body temperature
  5. Protein breakdown in skeletal muscle increases
  6. AA > (gluconeogenesis, synthesis of acute-phase proteins)
  7. Protein turnover is not regulated by nutrient requirements but continues even when sufficient energy and protein are supplied, leading to loss of muscle mass
  8. Blunted responses to nutritional treatments
  9. Inflammation leads to symptoms affecting nutrition which leads to low ink

front 7

Malnutrition Categories

back 7

  1. Disease related malnutrition with inflammation (chronic, acute)
  2. Disease related malnutrition without inflammation
  3. malnutrition without a disease (socioeconmic or psychological)

front 8

Impact of malnutrition on the individual

back 8

⬇️ Lower muscle strength

⬇️ Lower Quilty of Life

⬇️ Reduced ability of daily tasks

⬇️ Lower mood

⬇️ Lower recovery

⬆️ Higher risk of infections

⬆️ Higher risk of mortality

front 9

Consequences of malnutrition on Healthcare

back 9

  1. Increased length of stay
  2. Hospital admission
  3. Readmissions
  4. GP visits
  5. Home healthcare services
  6. Prescription costs

front 10

Consequences of malnutrition on clinical outcomes

back 10

  1. functional and physiological and metabolic effects
  2. poor quality of life
  3. less ability to preform ADL and dependancy

front 11

Impact of malnutrition on the society

back 11

Malnutrition results in increased use of health and social care resources and are associated with considerable excess costs

Compared with the well-nourished, malnourished individuals:

  • 2 x GP visits
  • 3 x hospital admissions
  • Increase packages of care
  • discharged to care homes
  • 2 x healthcare costs

front 12

% of patients at risk of malnutrition are residing in the community

back 12

93%

front 13

% of Malnutrition in the population

back 13

5%

front 14

% of Obesity in the population

back 14

27%

front 15

Why do people become malnourished? (psychological causes)

back 15

  1. Dementia
  2. Depression
  3. Bereavement
  4. Mental illness
  5. Anxiety
  6. Apathy
  7. Motivation
  8. Loneliness
  9. Self-esteem
  10. Independence
  11. Substance abuse

front 16

Why do people become malnourished? (social causes)

back 16

  1. Financial issues
  2. Social isolation
  3. Access to shops
  4. Access to care services
  5. Social networks

front 17

Why do people become malnourished? (clinical causes)

back 17

  1. Disease severity
  2. Inflammatory response
  3. GI function
  4. Pain
  5. Co-morbidities
  6. Dentition
  7. Swallowing difficulties
  8. Medical interventions
  9. Surgery
  10. Medication

front 18

% patients admitted to hospital are malnourished

back 18

30%

front 19

% patients discharged from hospital weigh less than on admission

back 19

Up to 70%

front 20

Nutrition screening tools

back 20

  1. Nutrition Risk Score 2002 (NRS-2002)
  2. Mini Nutritional Assessment-short form (MNA-SF)
  3. Malnutrition Universal Screening Tool (MUST)

front 21

Common elements between screening tools

back 21

  1. Weight (% weight change)
  2. Height
  3. Body mass index (BMI)
  4. Change in dietary intake
  5. Acute disease effect

front 22

Nutrition Screening recommendations

back 22

Inpatients: First time when admitted, re-screened weekly

Outpatients: First clinic visit, when there is a clinical concern

People in care homes: First time when admitted, re-screened monthly, when there is a clinical concern

All people: First contact with their GP, when there is a clinical concern

front 23

NCP (Assessment)

back 23

  1. Anthropometry i.e. weight and body composition
  2. Biochemical and other laboratory data
  3. Clinical condition e.g. disease severity, poly-morbidity, medications
  4. Dietary intake i.e. current, past and future
  5. Environmental, psychological and social issues
  6. Functional status e.g. handgrip strength, activities of daily living

front 24

“Obesity paradox”

back 24

In chronic illness and old age, higher BMI associated with improved survival and decreased morbidity

front 25

Dietary intake methods

back 25

Interview techniques 24-hour recall, Diet History

Record techniques Food record chart, Dietary diary, Weighed intake

front 26

Why should we treat malnutrition?

back 26

  • Patients eat more, have better outcomes and are less likely to die
  • Early identification and treatment of malnutrition would save the NHS
  • Malnutrition is the sixth largest source for NHS savings
  • Tailored nutritional therapy in hospital results in better outcomes and lower mortality than hospital diet.

front 27

What are we aiming to achieve?

back 27

Intake: A change in behaviour that results in increased nutrient intake and/or improved diet quality

Body composition: improved weight (or minimise weight loss), lean body mass, fat mass?

Patient- centred outcomes: improved functional status e.g. activities of daily living, quality of life, patient satisfaction

Decreased symptoms and complications, costs to the NHS

front 28

Interventions

back 28

1. Dietary counselling

2. Food fortification

3. Oral nutrition support

4. Enteral nutrition

5. Parenteral nutrition

front 29

Supportive interventions

back 29

  1. Protected mealtimes
  2. Red trays and feeding assistance
  3. Help with shopping, menu planning and meal
  4. preparation from paid and informal carers
  5. Home meal delivery services
  6. Lunch clubs and social eating
  7. Befriending services
  8. Cookery classes

front 30

Routes of Enteral Feeding

back 30

  1. Nasogastric/duodenal/jejunal
  2. Orogastric
  3. Gastrostomy/
  4. gastrojejunostomy
  5. Jejunostomy

front 31

Aims of monitoring

back 31

1. To ensure nutrition support is provided safely, and to detect and treat clinical complications as early and effectively as possible.

2. To assess the extent to which nutritional objectives have been reached.

3. To alter the type of nutrition support, or the components of the regimen, to improve its effectiveness and to minimise or prevent metabolic complications.