Define Malnutrition (2005)

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

Define Malnutrition (2017)

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

What are the two major pathophysiological pathways of malnutrition?

• 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

How does the body adapt to energy or nutrient deficiency?

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)

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

60 days

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

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

Malnutrition Categories

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

Impact of malnutrition on the individual

⬇️ Lower muscle strength

⬇️ Lower Quilty of Life

⬇️ Reduced ability of daily tasks

⬇️ Lower mood

⬇️ Lower recovery

⬆️ Higher risk of infections

⬆️ Higher risk of mortality

Consequences of malnutrition on Healthcare

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

Consequences of malnutrition on clinical outcomes

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

Impact of malnutrition on the society

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

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

93%

% of Malnutrition in the population

5%

% of Obesity in the population

27%

Why do people become malnourished? (psychological causes)

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

Why do people become malnourished? (social causes)

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

Why do people become malnourished? (clinical causes)

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

% patients admitted to hospital are malnourished

30%

% patients discharged from hospital weigh less than on admission

Up to 70%

Nutrition screening tools

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

Common elements between screening tools

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

Nutrition Screening recommendations

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

NCP (Assessment)

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

“Obesity paradox”

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

Dietary intake methods

Interview techniques 24-hour recall, Diet History

Record techniques Food record chart, Dietary diary, Weighed intake

Why should we treat malnutrition?

• 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.

What are we aiming to achieve?

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

Interventions

1. Dietary counselling

2. Food fortification

3. Oral nutrition support

4. Enteral nutrition

5. Parenteral nutrition

Supportive interventions

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

Routes of Enteral Feeding

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

Aims of monitoring

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.