Identifying the high-risk patient (And… determining nutrition risk levels)

Malnutrition

A state of inadequate or excessive nutrition that results in changes in body composition, function, and clinical outcomes; diagnosis requires at least 2 diagnostic criteria.

AND and ASPEN malnutrition criteria

Criteria established by the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition for diagnosing malnutrition.

Minimum criteria for diagnosing malnutrition

At least 2 malnutrition diagnostic criteria must be present.

Malnutrition diagnostic criteria

Insufficient energy intake, weight loss, loss of body fat, loss of muscle mass, fluid accumulation, and reduced grip strength.

PES signs and symptoms for malnutrition

The specific diagnostic criteria and supporting data used in the signs and symptoms section of a PES statement.

Malnutrition in acute illness or injury

Malnutrition occurring in the setting of an acute illness or injury, usually lasting less than 3 months, with concurrent inflammation.

Examples of acute illness-related malnutrition

Car accidents, burns, and sudden-onset infections.

Malnutrition in chronic illness

Malnutrition occurring with a long-term chronic disease and concurrent inflammation.

Examples of chronic illness-related malnutrition

Cancer, COPD, chronic kidney disease, dialysis, and congestive heart failure.

Malnutrition due to social or environmental circumstances

Malnutrition caused by inadequate food access or intake without concurrent inflammation.

Examples of social/environmental malnutrition

Food insecurity, eating disorders, hunger strikes, and inadequate oral intake without inflammation.

Severity of malnutrition

Each category of malnutrition can be classified as non-severe or severe.

Energy intake as a malnutrition criterion

Compare the patient's actual energy intake with their estimated energy needs and consider how long intake has been inadequate.

Acute illness energy intake

A shorter period of inadequate intake can be significant because acute malnutrition develops rapidly.

Chronic/social-environmental energy intake

A longer period of inadequate intake is generally considered because these types of malnutrition develop more slowly.

Weight loss as a malnutrition criterion

Evaluate the percentage of weight lost and the time period over which the loss occurred.

Specific weight loss documentation

Document the percentage and time period, such as 7% weight loss in 1 month, rather than simply saying "weight loss."

Body fat loss

Loss of subcutaneous fat assessed during a nutrition-focused physical exam (NFPE) and used as a malnutrition diagnostic criterion.

Muscle mass loss

Loss of muscle tissue assessed during an NFPE and used to diagnose and determine the severity of malnutrition.

Fluid accumulation

Excess fluid that can mask weight loss and may occur with conditions such as end-stage renal disease.

Fluid accumulation and weight loss

Do not use both as your only two diagnostic criteria because they may represent the same underlying problem.

Grip strength

A measure of functional muscle strength that can be used as a malnutrition diagnostic criterion.

Hand dynamometer

A device used to measure grip strength.

Reduced grip strength

May occur before obvious changes in muscle structure and can count as one malnutrition diagnostic criterion.

Grip strength standards

Based on factors such as age, sex, and the specific dynamometer being used.

Albumin and malnutrition

Albumin is not a defining characteristic or diagnostic criterion for malnutrition because serum levels are strongly affected by inflammation and do not directly reflect recent nutrient intake.

Prealbumin and malnutrition

Prealbumin is not a malnutrition diagnostic criterion because serum levels do not directly reflect changes in nutrient intake.

Serum proteins and malnutrition

Albumin, prealbumin, and other serum proteins should not be used as the diagnostic criteria for malnutrition.

CRP (C-reactive protein)

A laboratory marker of inflammation that can help indicate the presence and degree of inflammation.

Albumin and inflammation

Albumin can decrease during inflammation, so a low albumin level does not necessarily mean inadequate protein intake.

Specific PES documentation

Use specific numbers, percentages, and time periods instead of vague statements.

Example of specific energy intake documentation

"Consumed <50% of estimated energy needs of 2,300 kcal for 7 days."

Chronic disease-related malnutrition

Chronic calorie and/or protein deficit combined with chronic inflammation in the setting of chronic disease.

Chronic disease-related malnutrition examples

COPD, cancer, dialysis/end-stage renal disease, congestive heart failure, and other chronic diseases.

Chronic disease-related malnutrition development

Develops gradually due to long-term inadequate intake and chronic inflammation.

Anthropometrics in chronic disease-related malnutrition

Often show significant weight loss and muscle wasting.

Visceral proteins in chronic disease-related malnutrition

Often remain relatively preserved compared with acute disease-related malnutrition.

Physical characteristics of chronic disease-related malnutrition

Fatigue, generalized weakness, lethargy, weight loss, and muscle wasting.

Cachexia

A condition involving severe skeletal muscle and body mass wasting that can occur with chronic disease.

Chronic Inflammation

Interleukins

Inflammatory signaling molecules released during inflammation that can contribute to metabolic changes and tissue breakdown.

Tumor necrosis factors (TNF)

Inflammatory molecules that contribute to the metabolic response to chronic disease and can promote tissue breakdown.

Catecholamines

Hormones associated with the fight-or-flight response that can increase energy use during illness and stress.

Lipolysis

Breakdown of fat for energy.

Proteolysis

Breakdown of protein, including muscle protein, for energy.

Lipogenesis

Creation and storage of fat.

Proteosynthesis

Creation/synthesis of proteins.

Metabolic changes in chronic disease

Inflammation can increase energy expenditure, lipolysis, and proteolysis while decreasing lipogenesis, proteosynthesis, and energy intake.

Acute disease-related malnutrition

Insufficient protein and/or calorie intake combined with a marked inflammatory response during acute illness or injury.

Acute disease-related malnutrition development

Develops rapidly, often within a short period following severe illness, injury, or stress.

Examples of acute disease-related malnutrition

Burns, car accidents, severe infections, and other sudden injuries or illnesses.

Anthropometrics in acute disease-related malnutrition

Weight and BMI may initially be normal or high because the condition develops rapidly.

BMI and malnutrition

Any BMI can have malnutrition; a normal or high BMI does not rule out malnutrition.

Visceral proteins in acute disease-related malnutrition

May become severely depressed during acute inflammation.

Edema in acute illness

Fluid may accumulate because inflammation can cause changes in capillary permeability, potentially masking weight loss.

Immune function in acute disease-related malnutrition

May be compromised.

Physical characteristics of acute disease-related malnutrition

Poor wound healing and changes in hair may occur.

D5W

Dextrose 5% in water, an IV solution that provides carbohydrate but does not provide protein or enough calories to meet full nutritional needs.

Starvation-related malnutrition

Malnutrition caused by a severe calorie deficit without concurrent inflammation.

Who is at risk for starvation-related malnutrition?

Individuals with limited food access, food insecurity, eating disorders, hunger strikes, or other situations causing prolonged inadequate intake.

Nutrition rehabilitation

The process of gradually restoring calories and protein to a malnourished patient.

Chronic/starvation nutrition rehabilitation

Calories and protein should be added back slowly because malnutrition developed over a longer period.

Starvation factor

A factor of approximately 0.85 that can be used to account for the body's reduced energy expenditure during starvation.

Refeeding syndrome

A potentially life-threatening condition that can occur when nutrition is reintroduced too rapidly to a severely malnourished patient.

Refeeding syndrome

Dangerous metabolic and electrolyte changes that can occur when nutrition is reintroduced to a severely malnourished patient.

Who is at risk for refeeding syndrome?

Severely malnourished patients, especially those with prolonged inadequate intake, significant weight loss, low BMI, severe muscle/fat loss, or low electrolytes.

Nutrition that can trigger refeeding syndrome

Any mode of nutrition, including oral, enteral, parenteral, and even dextrose-containing IV fluids.

Most severe complication of refeeding syndrome

Death.

Hallmark electrolyte of refeeding syndrome

Low phosphorus (hypophosphatemia).

Electrolytes monitored during refeeding

Phosphorus, potassium, and magnesium.

Thiamine and refeeding syndrome

Thiamine can become depleted during prolonged starvation and should be supplemented in patients at risk for refeeding syndrome.

Refeeding Mechanism

Refeeding insulin response

Reintroducing carbohydrates increases insulin, causing glucose and electrolytes to move into cells.

Electrolyte shifts during refeeding

Increased insulin causes phosphorus, potassium, and magnesium to shift into cells, potentially causing dangerously low blood levels.

Complications of electrolyte depletion

Can include cardiac arrhythmias, respiratory problems, neurological problems, and potentially death.

Adult moderate refeeding risk

Generally requires 2 risk criteria.

Adult significant refeeding risk

Generally requires 1 significant risk criterion.

BMI moderate refeeding risk

BMI 16–18.5.

BMI significant refeeding risk

BMI <16.

Weight loss moderate refeeding risk

Approximately 5% weight loss in 1 month.

Weight loss significant refeeding risk

Approximately 7.5% weight loss in 3 months or 10% weight loss in 6 months.

Oral intake moderate refeeding risk

Negligible intake for approximately 5–6 days or intake below the specified percentage of estimated needs.

Oral intake significant refeeding risk

Negligible intake for more than 7 days or very low intake for the specified period.

Electrolytes associated with refeeding risk

Low potassium, phosphorus, or magnesium before feeding.

Body fat loss and refeeding risk

Moderate or severe body fat loss increases refeeding risk.

Muscle mass loss and refeeding risk

Muscle loss increases the risk of refeeding syndrome, with greater loss indicating greater risk.

Conditions associated with refeeding risk

Cancer, AIDS, food insecurity, eating disorders, dysphagia, prolonged vomiting, and other conditions associated with prolonged inadequate intake.

Pediatric refeeding risk levels

Mild, moderate, and significant risk based on the number and severity of risk criteria.

Pediatric BMI-for-age

A growth assessment used for children ages 2–20 years.

Z-score

Indicates how far a measurement is from the mean of a reference population.

MUAC

Mid-upper arm circumference; a measure that can be used to assess body composition and nutritional status in children.

Pediatric refeeding treatment

Nutrition is generally started at no more than approximately 40–50% of goal, with close electrolyte monitoring.

Adult starting calories for refeeding

Approximately 10–20 kcal/kg for the first 24 hours.

Advancing nutrition during refeeding

Increase nutrition by approximately 33% of the goal every 1–2 days, depending on the patient's condition and electrolyte status.

Electrolyte monitoring before refeeding

Check potassium, magnesium, and phosphorus before starting nutrition.

Electrolyte monitoring during high-risk refeeding

Monitor electrolytes approximately every 12 hours for the first 3 days in high-risk patients.

Electrolyte repletion

Replace low potassium, magnesium, or phosphorus as medically indicated before or during nutrition advancement.

Nutrition advancement with low electrolytes

If electrolytes remain significantly low, nutrition may need to be held at the current rate rather than advanced.

Thiamine before refeeding

Adults at risk should receive approximately 100 mg thiamine before feeding.

Thiamine during refeeding

Approximately 100 mg/day for 5–7 days or longer when indicated.