Hospital Nutrition: Malnutrition, Enteral & Dietary Guidelines

Inadequate energy intake

Consuming fewer calories than required for metabolic functions.

Unintentional weight loss

A significant drop in body weight without intentional dieting.

Loss of muscle mass

Muscle wasting, often assessed through physical examination.

Loss of subcutaneous fat

Reduction in fat stores, particularly in areas like the face, arms, and ribs.

Fluid accumulation (Edema)

Swelling that may mask weight loss, making malnutrition harder to detect.

Diminished functional status

Measured by reduced handgrip strength, indicating muscle weakness.

Purpose of a Nutrition Screen

Early identification of individuals at risk for malnutrition.

Guidance for healthcare teams

Guidance for healthcare teams in preventing and managing malnutrition.

Nutrition Therapy Guidelines for Clients at Nutrition Risk

Increase nutrient-dense foods to maximize intake of essential vitamins and minerals.

Small, frequent meals

Provide small, frequent meals to accommodate reduced appetite.

Oral nutrition supplements

Use oral nutrition supplements when dietary intake is insufficient.

Modify food consistency

Modify food consistency for clients with swallowing difficulties.

Monitor weight and intake

Monitor weight and intake regularly to track progress and adjust interventions.

Weight changes

Sudden or gradual weight loss over time.

Appetite fluctuations

Reduced desire to eat or difficulty consuming meals.

Dietary intake patterns

Identifying deficiencies in essential nutrients.

Medical conditions

Chronic illnesses that may contribute to malnutrition.

Physical signs

Muscle wasting, fat loss, edema, and symptoms of nutrient deficiencies (e.g., pale skin, brittle nails).

Strategies to Promote Optimal Intake

Encourage nutrient-rich meals tailored to individual preferences.

Clear liquid diet

Includes broth, gelatin, and juices for easy digestion.

Pureed diet

Smooth-textured foods for clients with severe swallowing difficulties.

Mechanically altered diet

Soft foods that require minimal chewing, such as mashed potatoes and ground meats.

Low-sodium diet

Helps control hypertension and heart disease.

Diabetic diet

Regulates blood sugar levels with balanced carbohydrate intake.

Renal diet

Limits potassium, phosphorus, and sodium for kidney disease management.

High-protein diet

Supports wound healing and muscle maintenance.

Standard formulas

Balanced macronutrient content for general supplementation.

High-protein formulas

Designed for muscle maintenance and recovery.

Fiber-enriched formulas

Support digestive health and prevent constipation.

Disease-specific formulas

Tailored for conditions like diabetes or renal disease.

Standard Enteral Formulas

Contain intact proteins and complex carbohydrates, suitable for individuals with normal digestion.

Hydrolyzed Formulas

Contain proteins broken down into peptides or amino acids, designed for patients with impaired digestion or absorption (e.g., those with malabsorption disorders).

Choosing the Most Appropriate Enteral Formula

Consider nutritional needs, digestive capabilities, and medical conditions. Standard formulas for patients with normal digestion. Hydrolyzed formulas for patients with gastrointestinal disorders. High-calorie formulas for patients with increased energy needs. Disease-specific formulas for conditions like diabetes or renal disease.

Continuous Feeding

Steady nutrient delivery, reduces aspiration risk, but requires a pump.

Intermittent Feeding

Mimics normal eating patterns, allows mobility, but may cause GI discomfort.

Bolus Feeding

Quick administration, convenient, but increases aspiration risk.

Barriers to Receiving Prescribed Enteral Formula

Mechanical issues (tube clogging, displacement). Patient intolerance (nausea, diarrhea). Inadequate monitoring (missed feedings, incorrect administration). Financial constraints (cost of specialized formulas).

Ways to Maximize Tube-Feeding Tolerance

Start with a slow rate and gradually increase. Ensure proper tube placement before feeding. Use appropriate formula based on patient needs. Monitor for signs of intolerance and adjust accordingly.

Signs of Tube-Feeding Intolerance

Signs: Abdominal distension, nausea, vomiting, diarrhea.

Interventions for Tube-Feeding Intolerance

Adjust feeding rate, switch to hydrolyzed formula, ensure proper hydration, use anti-nausea medications if needed.

Benefits of Enteral Nutrition Over Parenteral Nutrition

Preserves gut function, reducing risk of atrophy. Lower risk of infection compared to IV nutrition. More cost-effective and easier to administer.

Indications for Parenteral Nutrition

Severe malabsorption (e.g., short bowel syndrome). Intestinal obstruction preventing enteral feeding. Severe pancreatitis requiring bowel rest. Post-surgical recovery when enteral feeding is not feasible.

Components of Parenteral Nutrition

Macronutrients: Amino acids (protein), dextrose (carbohydrates), lipids (fats). Micronutrients: Electrolytes, vitamins, minerals. Fluids: Hydration support. Medications: Insulin, heparin (if needed).

Potential Metabolic Complications of Parenteral Nutrition

Hyperglycemia due to high dextrose content. Electrolyte imbalances (hypokalemia, hypophosphatemia). Liver dysfunction from excessive lipid intake. Infection risk due to IV catheter use.

Value of BMI in Classifying Obesity

Provides a general estimate of body fat based on height and weight.

Shortcomings of BMI in Classifying Obesity

Does not differentiate between muscle and fat; may misclassify athletes or older adults.

Value of Waist Circumference

Helps assess central obesity, which is linked to metabolic diseases.

Shortcomings of Waist Circumference

Does not account for overall body fat distribution.

Assessing Disease Risk Based on BMI

Higher BMI (≥30): Increased risk of heart disease, diabetes, hypertension.

Assessing Disease Risk Based on Waist Circumference

Men ≥40 inches, Women ≥35 inches → Higher risk of cardiovascular disease and insulin resistance.

Three Components of Lifestyle Therapy for Weight Management

Dietary Modifications: Reducing calorie intake while maintaining nutrient balance. Physical Activity: Regular exercise to support metabolism and muscle retention. Behavioral Strategies: Cognitive restructuring, self-monitoring, and stress management.

General Calorie Targets for Weight-Loss Diets

Men: ~1,500-1,800 kcal/day. Women: ~1,200-1,500 kcal/day. Goal: Create a 500-750 kcal deficit per day for gradual weight loss.

Health Benefits of Mediterranean Diet

Rich in healthy fats (olive oil, nuts), lean proteins, and fiber. Supports heart health and reduces inflammation.

DASH Diet

Focuses on low sodium, high potassium, and fiber. Helps lower blood pressure and supports weight management.

Low-Carb Diets

Effective for short-term weight loss but may lack fiber.

Intermittent Fasting

Helps regulate metabolism but requires adherence.

Plant-Based Diets

High in fiber, supports satiety and gut health.

Consistent Meal Patterns

Avoiding extreme dieting.

Regular Physical Activity

≥150 minutes/week.

Self-Monitoring

Tracking food intake and weight.

Social Support

Engaging in healthy communities.

BMI for Weight-Loss Medications

BMI ≥30 or BMI ≥27 with obesity-related conditions.

Orlistat

Fat absorption blocker.

GLP-1 Agonists

Appetite regulation.

General Diet Progression After Bariatric Surgery

Clear liquids (first few days), full liquids (protein shakes, broths), pureed foods (soft proteins, blended vegetables), soft solids (lean meats, cooked vegetables), regular diet (small, nutrient-dense meals).

Dumping Syndrome

Avoid high-sugar foods.

Nutrient Deficiencies

Supplement iron, B12, calcium, vitamin D.

Dehydration

Encourage small, frequent sips of fluids.

Anorexia Nervosa

Gradual caloric increase to restore weight. Focus on nutrient-dense foods and psychological support.

Bulimia Nervosa

Balanced meal plans to prevent binge-purge cycles. Electrolyte monitoring to prevent imbalances.

Binge-Eating Disorder

Structured meal timing to reduce impulsive eating. Behavioral therapy to address emotional triggers.

Ebb Phase

Lasts 24-48 hours. Characterized by shock, hypovolemia, and diminished tissue oxygenation.

Flow Phase

Begins after hemodynamic stability is restored. Increased energy expenditure due to the body's attempt to heal.

Recovery Phase

Metabolic rate normalizes as healing progresses. Nutritional support is crucial to prevent malnutrition.

Enteral Nutrition

Preserves gut integrity, reducing the risk of bacterial translocation.

Parenteral Nutrition

Lower risk of infection compared to IV nutrition.

Caloric Needs

25-30 kcal/kg/day for critically ill patients. Adjusted based on severity of illness and metabolic demands.

Protein Needs

1.2-2.0 g/kg/day to prevent muscle loss. Higher protein intake required for burn or trauma patients.

Refeeding Syndrome

Occurs when nutritional support is restarted too quickly after prolonged starvation.

Signs of Refeeding Syndrome

Hypophosphatemia → Weakness, respiratory failure. Hypokalemia → Arrhythmias, muscle cramps. Hypomagnesemia → Neurological symptoms.

Increasing Protein and Calorie Intake

Add protein-rich foods (eggs, lean meats, dairy). Use high-calorie additions (nut butters, oils, avocado). Encourage frequent, nutrient-dense meals.

High-Calorie, High-Protein Menu

A menu consisting of small frequent meals that are high in calories and protein.

Ways to Promote Eating in People with Anorexia

Encourage nutrient-dense foods, create a pleasant eating environment, offer small frequent meals, and avoid pressure in food choices.

Nutrition Interventions for People with Nausea

Eat small, bland meals, avoid strong odors, stay hydrated with clear liquids, and consider ginger and peppermint.

Five Levels of Food Textures in the International Dysphagia Diet

Level 7: Regular - Normal texture, no modifications; Level 6: Soft & Bite-Sized - Easy to chew; Level 5: Minced & Moist - Small, soft pieces; Level 4: Pureed - Smooth, uniform consistency; Level 3: Liquidized - Completely smooth, no lumps.

Five Levels of Liquid Consistencies in the International Dysphagia Diet

Thin - Normal liquids; Slightly Thick - Requires minimal effort; Mildly Thick - Slower flow; Moderately Thick - Requires more effort; Extremely Thick - Pudding-like consistency.

Nutrition and Lifestyle Recommendations for GERD

Avoid trigger foods, eat smaller meals, limit caffeine and alcohol, and maintain a healthy weight.

Nutrition Therapy for Peptic Ulcer Disease

Increase fiber intake, avoid irritants, consume probiotic-rich foods, and ensure adequate protein.

Nutrition Strategies for Clients with Gastroparesis

Eat small, frequent meals, choose low-fat low-fiber foods, stay hydrated with electrolyte-rich fluids, and consider liquid nutrition.

Nutrition Therapy for Dumping Syndrome

Eat smaller, frequent meals, limit simple sugars, increase protein and fiber, and avoid drinking fluids with meals.

Modifying a Regular Diet to Be High in Fiber

Increase intake of whole grains, consume more fruits and vegetables, include legumes and nuts, and drink plenty of water.

Nutrition Therapy Recommendations for Diarrhea

Increase fluid intake, consume soluble fiber, avoid high-fat and spicy foods, and introduce probiotics.

Nutrition Interventions for Malabsorption Syndrome

Small, frequent meals, supplementation of deficient nutrients, use medium-chain triglycerides, and avoid gluten and lactose.

Modifying a Regular Diet to Be Low in Lactose

Choose lactose-free dairy alternatives, opt for aged cheeses, use lactase enzyme supplements, and increase calcium intake through non-dairy sources.

Sources of Gluten

Wheat-based products (bread, pasta, cereals). Barley and rye (beer, malt products). Processed foods (soups, sauces, dressings with hidden gluten). Certified gluten-free alternatives (rice, quinoa, corn-based products).

Short Bowel Syndrome Nutrition Interventions

High-calorie, high-protein diet to compensate for nutrient loss. Frequent, small meals to improve absorption. Use oral rehydration solutions to prevent dehydration. Supplement vitamins and minerals (B12, iron, fat-soluble vitamins).

Nonalcoholic Liver Disease Nutrition Interventions

Reduce saturated fats and refined sugars to prevent fat accumulation. Increase fiber intake to support liver function. Consume lean proteins (fish, poultry, legumes). Maintain a healthy weight through balanced nutrition.

Cirrhosis Nutrition Therapy

Limit sodium intake to prevent fluid retention. Ensure adequate protein intake to prevent muscle wasting. Supplement vitamins and minerals (B-complex, zinc). Avoid alcohol to reduce liver stress.

Low-Fat Diet

Limits saturated and trans fats. Focuses on lean proteins, whole grains, and vegetables. Used for heart disease, gallbladder issues, and liver conditions.

Regular Diet

Includes moderate amounts of fats. Provides balanced macronutrients. Suitable for general health maintenance.