Malnutrition and Nutritional Assessment

what is malnutrition?

a state of nutrient imbalance where energy (calories) intake either exceeds (overnutrition/obesity) or does not meet energy needs (undernutrition)

undernutrition can occur secondary to:

inadequate intake, poor absorption, and increased utilization of energy

is malnutrition most often associated with overnutrition or undernutrition?

undernutrition

how is starvation-related malnutrition defined

a prolonged duration of inadequate intake or feeding intolerance

what is typically a chronic process with unintentional weight loss

starvation-related malnutrition

what may influence starvation-related malnutrition?

behavioral, socioeconomic, and environmental factors

examples of undernutrition

disordered eating, depression, inflammatory bowel disease, major burns/trauma/infection

examples of starvation-related malnutrition

inadequate food supply, anorexia nervosa, other disordered eating patterns, major depression, and feeding aversions

how is disease-related malnutrition defined

disease associated with an inflammatory state which results in increased energy (calories) or protein needs

what is chronic disease-related malnutrition?

lasting for 3 or more months with mild-moderate degree of inflammation

examples of chronic disease-related malnutrition

inflammatory bowel disease, cancer, organ failure, cystic fibrosis, and malabsorption

what is acute disease-related malnutrition?

lasting for < 3 months with severe degree of inflammation

examples of acute disease-related malnutrition:

burns, trauma, traumatic brain injury, major surgery, serious infection

which type of malnutrition does not have inflammation

starvation-related malnutrition

what should be screened in patients to determine if they are at risk for malnutrition

medical history, surgical history, diet history, alcohol or substance use, gastrointentestinal disorders, nutritional supplements, and medications that can cause weight loss/gain

what should be assessed in patients to determine if they are at risk for malnutrition

objective data (weight, body mass index - BMI, intake- diet/fluid, laboratory data (inflammatory markers), malnutrition classification (under vs obesity), and severity + risk for refeeding syndrome

what are the two quick screening questions for malnutrition

Has there been a recent weight loss of at least 5-10%?

Has there been inadequate intake for at least 1-2 weeks

if either malnutrition screening question is yes, what should be done?

patient should be referred for full nutritional assessment

Patient history malnutrition risk factors:

acute/chronic inflammatory diseases associated with malnutrition, socioeconomic factors that may result in food insecurities or reduced intake, altered absorption of nutrients, medications, poor nutritional habits, and alcohol/substance abuse

what is the other name for actual body weight (ABW)

total body weight (TBW)

how to convert from pounds to kg

1 kg = 2.2 lbs

IBW equation for males =

50 kg + (2.3 kg * total inches > 60)

IBW equation for females =

45.5 kg + (2.3 * total inches > 60)

how to calculate Adjusted body weight (AdjBW)

IBW + (0.4 * (TBW-IBW))

how to calculate BMI from kgs

weight (Kg) / height (m² )

how to calculate BMI from lbs

[weight (pounds) / height (inches² )] * 703

how to calculate % difference ABW vs. IBW

(ABW/IBW) * 100%

what is the BMI for underweight category

< 18.5

what is the % difference for the underweight category

ABW < 90% IBW

what is the BMI for normal/healthy category

18.5 - 24.9

what is the % difference for the normal/healthy category

ABW is 90-120% IBW

what is the BMI for the overweight category

25-29.9

what is the % difference for the overweight category

ABW is > 120 to < 150%

what is the BMI for the obese (Class I + Class II) category

30-39.9

what is the % difference for the obese (Class I + Class II) category

ABW is >= 150 to < 200%

what is the BMI for the severe obesity (Class III) category

>= 40

what is the % difference for the severe obesity (Class III) category

ABW is >= 200% IBW

What are the subcategories of underweight?

Mild malnutrition, moderate malnutrition, and severe malnutrition

what is the BMI for the mild malnutrition subcategory

17-18.5

what is the % difference for the mild malnutrition subcategory

ABW is 80-89% IBW

what is the BMI for the moderate malnutrition subcategory

16-16.9

what is the % difference for the moderate malnutrition subcategory

ABW is 70-79% IBW

what is the BMI for the severe malnutrition subcategory

< 16

what is the % difference for the severe malnutrition subcategory

ABW is < 69% IBW

what is the criteria for malnutrition diagnosis

reported insufficient intake of calories (at <75% of daily needs for at least 1-2 weeks), recent unintentional weight loss (loss of at least 10% of body weight in 6 months or 5% in one month), decreased muscle mass, decreased SQ fat, fluid accumulation, decreased functional status (such as grip strength)

what is the principle “start low, go slow” utilized in?

treatment of severe malnutrition

why is start low, go slow utilized in malnutrition?

to ensure medical stabilization and prevent refeeding syndrome

what is refeeding syndrome?

occurrence of electrolyte abnormalities in severely malnourished patients during initiation of nutritional supper (calories) in an individual who has been exposed to undernourishment for a substantial amount of time

why is refeeding syndrome dangerous

undernutrition leads to overall reduction in total body stores of energy, electrolytes, and vitamins ——> initiation of nutritional therapy, containing glucose shifts to anabolic state ——> insulin release will drive electrolytes intracellularly, specifically - potassium, phosphate, and magnesium

what are the activity factor values for patients confined to bed

1.2

what are the activity factor values for patients out of bed, ambulatory?

1.3

what are the stress factor values for patients getting minor surgery

1.2

what are the stress factor values for patients with infections

1.4

what are the stress factor values for patients with major trauma, sepsis, and burns 0-30% BSA

1.5

what are the stress factor values for patients with burns > 30% BSA

1.5-2.0

which patient specific factor needs increased energy (kcal) goals?

critically ill (infection, burns, trauma)

which patient specific factor needs decreased fluid than goal?

Kidney dysfunction and heart failure

T/F: utilization of supplemental nutrition is based on patient-specific assessment rather than a diagnosis of presence of a particular disease state

true

what needs to be evaluated to determine route of administration of nutritional supplementation?

feasibility of utilizing the gut

what is parenteral nutrition reserved for?

if intestinal tract is not functional/unable to access and instances where energy needs/goals are greater than patient intolerance

what is the order of nutritional supplementation

oral intake —→ enteral nutrition (via tube) ——> parenteral nutrition (intravenous)

which patients should receive enteral nutrition within 24-48 hours of admission to the hospital

patients in the ICE, in the high-risk nutrition or the malnourished patient

which patients can be considered for a delay in initiation of enteral nutrition

hospitalized patients who are low risk, well nourished, and expected to resume volitional oral intake within 5-7 days of admission

which patients should be given enteral nutrition cautiously

patients at risk for refeeding and in patients with symptoms of GI intolerance

which adult patients should receive parenteral nutrition

well-nourished stable adult unable to receive significant enteral nutrition and nutritionally-at-risk patients unlikely to achieve goal with enteral nutrition

which adult patients can receive PN nutrition after 7 days

well-nourished stable adult unable to receive significant enteral nutrition

which adult patients can receive PN nutrition within 3-5 days

nutritionally-at-risk patients unlikely to achieve goal with enteral nutrition

what are some examples of nutritionally-at-risk patients unlikely to achieve goal with enteral nutrition?

patients with involuntary weight loss (10% within 6 months or 5% within 1 month), BMI < 18.5 kg/m2, increased metabolic requirements, or altered diets and/or diet schedules

when should parenteral nutrition be initiated in patients with baseline moderate-severe malnutrition diagnosis where EN is not feasable?

initiate as soon as possible

when can you initiate parenteral nutrition in patients with metabolic/hemodynamic instability?

not until the patient’s condition improves

when is it recommended to initiate PN in infants

within 1-3 days if the patient is unlikely to tolerate EN for extended time

when is it recommended to initiate PN in children/adolescents?

initiate within 4-5 days if unlikely ro tolerate EN for extended time

T/F: if a pediatric patient presents with a self-limited illness likely to resolve it may be possible to delay PN for up to 7 days

true

why do pediatric patients have shorter times to initiation?

they have higher energy requirements and less metabolic stores/reserves available

when to initiate parenteral nutrition in very-low birth weight neonates (< 1.5 kg)

initiate promptly after birth

when is parenteral nutrition indicated for preterm and critically ill term neonates?

initiate when enteral nutrition is unable to meet the energy requirements for growth

which patient population can develop essential fatty acid deficiency if fats are withheld from diet for 3 days?

neonates

examples of patients of any age that qualify for PN use due to impaired absorption

those with short bowel syndrome, congenital anomaly involving intestines (ex: gastroschisis), and interstitial fistula with high output

examples of patients of any age that qualify for PN use due to mechanical/motility limitations

those with bowel obstructions, Ileus, or inflammatory disease

examples of patients of any age that qualify for PN use due to needing “bowel rest”

pancreatitis, ischemic bowel, or pre/post- operative

examples of patients of any age that qualify for PN use due to inability to utilize the gut:

very low birth weight neonate, those with hemodynamic instability, or those with severe gastrointestinal bleeding