lecture 7 malnutrition

Donation and Malnutrition

  • Key Concepts:

    • Malnutrition is a significant and often neglected health crisis tied to starvation and poverty.

    • Terms related to malnutrition include: hunger, disease, health, homelessness, and the challenge of eating properly.

    • Related social issues include global hardship and the role of charities in addressing these problems.

Learning Objectives

  • Definitions and Concepts:

    • Define malnutrition, its types, causes, and consequences.

    • Understand the risk factors leading to malnutrition.

    • Identify three types of malnutrition relevant to hospital settings.

    • Describe factors contributing to malnutrition or decline in nutritional status during hospitalization.

    • Outline the diagnostic criteria for identifying malnutrition.

    • Distinguish between regular and modified diets and their indications.

    • Review enteral and parenteral nutrition indications, advantages, disadvantages, and potential complications.

    • Understand different administration methods for enteral and parenteral nutrition (EN/PN).

    • Comprehend EN/PN formula compositions and their suitability for patients.

    • Understand Refeeding Syndrome, its complications, and high-risk populations.

  • Reading Material: Chapter 15 & 16 in textbook.

Malnutrition: Overview

  • Definition of Malnutrition:

    • Malnutrition is defined as the lack of sufficient nutrients in the body, which may arise from:

    • Not having enough to eat.

    • Not consuming the right types of food.

    • Being unable to utilize the food consumed effectively.

  • Consequences:

    • Untreated malnutrition can lead to:

    • Physical and mental disabilities.

    • Increased risk of disease and mortality.

    • Treatment should address underlying conditions and replace missing nutrients.

Malnutrition: Types

  • Types of Malnutrition:

    • Overnutrition:

    • Overweight and obesity.

    • Undernutrition:

    • Stunting/chronic malnutrition.

    • Wasting/acute malnutrition.

    • Underweight (acute and/or chronic malnutrition).

    • Severe and Moderate Acute Malnutrition:

      • Types include Marasmus, Kwashiorkor, and Marasmic Kwashiorkor.

    • Micronutrient Deficiency:

Malnutrition: Risk Factors

  • Medical Factors:

    • Hospitalization.

    • Chronic illnesses (cancer, diabetes, lung disease).

    • Dental issues.

    • Loss of taste/smell.

    • Involuntary weight loss.

    • Medication side effects.

    • Physical disabilities.

    • Poor appetite.

    • Malabsorption issues.

  • Lifestyle Factors:

    • Lack of food knowledge and cooking skills.

    • Loneliness and social isolation.

    • Inadequate food intake.

    • Food insecurity.

  • Mental Health Factors:

    • Conditions like anxiety, cognitive decline, depression, grief, and eating disorders.

Malnutrition in the Health Care Setting

  • Prevalence:

    • Approximately 1/3 of patients admitted to the hospital are malnourished.

    • Malnutrition can progress if untreated.

    • About 1/3 of well-nourished patients may develop malnutrition during extended hospital stays.

  • Consequences of Malnutrition:

    • Increased risk of pressure injuries and impaired wound healing.

    • Immune suppression leading to a higher chance of infections.

    • Muscle wasting.

    • Prolonged hospital stays.

    • Higher readmission rates.

    • Increased treatment costs.

Types of Malnutrition as per Etiology

  • Starvation-Related Malnutrition:

    • Resultant from chronic starvation without inflammation (e.g., anorexia nervosa).

  • Chronic Disease-Related Malnutrition:

    • Inflammation is chronic and of mild to moderate degree (e.g., organ failure, pancreatic cancer).

  • Acute Disease or Injury-Related Malnutrition:

    • Inflammation is acute and severe (e.g., major infections, burns, trauma).

Diagnostic Criteria for Malnutrition

  • To diagnose malnutrition, two of the following six criteria must be present:

    • Weight loss (assessed over a designated time).

    • Decreased food intake (over a specific period).

    • Loss of muscle mass.

    • Loss of fat mass.

    • Fluid accumulation.

    • Impaired functional status.

Nutrition Care Process

  • Essential Steps:

    • Nutrition monitoring and evaluation.

    • Screening for nutritional risk.

    • Comprehensive nutrition assessment.

    • Planning a nutrition intervention.

    • Establishing a nutrition diagnosis.

Importance of Nutrition Screening

  • Role of Nurses:

    • Nurses perform nutritional screening that informs the nutrition intervention process.

    • Standardized questions typically include:

    • Declines in appetite over the past three months.

    • Weight loss within the same timeframe.

    • Recent acute illness.

    • Recent diagnosis of dementia or depression.

    • Additional relevant questions can enhance screening effectiveness.

Nutrition Assessment in Hospitals

  • Key Components:

    • Food and nutrition-related history (dietary habits, appetite, weight).

    • Review of medical history and anthropometric data (body measurements).

    • Biochemical data relevant to nutritional status.

    • Nutrition-focused physical findings.

Nutrition Therapy for Malnutrition

  • Custom Nutrition Plans Include:

    • Suggested caloric intake should be between 25 to 30 cal/kg/day.

    • Adequate protein intake should be maintained at:

    • 1.2-1.5 g protein/kg/day for maintenance or restoration of lean body mass.

    • 1.5-2.0 g protein/kg/day post-surgery.

    • High protein oral nutrition supplements may be recommended to meet dietary needs.

    • Feeding methods should be designed for those unable to meet 50% of their protein and calorie needs orally.

Hospital Diets

  • Diet Manual Requirement:

    • Each healthcare facility must possess a diet manual outlining dietary protocol.

  • Diet Orders:

    • Diet orders originate from physicians and are communicated to the food service department.

    • Aim for the least restrictive dietary options.

Dietary Classifications

  • Regular Diet:

    • Unrestricted in macronutrient and micronutrient composition.

    • Restrictions may be based on individual preferences (e.g., vegetarian, kosher, halal).

  • Transitional Diets:

    • Examples include:

    • Clear Liquid Diet: (broth, tea, certain juices) functionality for pre-/post-surgical procedures.

    • Full Liquid Diet: (blended/pureed foods and liquids) used post-operatively or if chewing/swallowing is a concern.

  • Modified Diets:

    • Targeted changes in:

    • Food texture.

    • Nutrient quantity (increased or decreased).

    • Elimination of specific food categories.

Oral Nutrition Supplements (ONS)

  • Use in Patients:

    • Some patients may be unable/unwilling to eat sufficient food. Categories of supplements include:

    • Clear liquid supplements.

    • Milk-based drinks.

    • Prepared liquid supplements.

    • Specially prepared foods.

Nutrition Support: Enteral and Parenteral Nutrition

  • Enteral Nutrition (EN):

    • For patients with a functioning GI tract but cannot meet nutritional needs through ordinary consumption.

    • Can supplement or fulfill 100% of nutrition requirements.

Enteral Nutrition: Benefits Over Parenteral Nutrition

  • Advantages:

    • Lower infection and complication rates than parenteral nutrition.

    • Supports the immune system and gut-associated lymphoid tissue.

    • Maintains gut integrity and prevents bacterial translocation.

    • More cost-effective compared to parenteral nutrition.

Enteral Nutrition: Feeding Routes and Tube Types

  • Short-Term Feeding:

    • Transnasal tubes, including:

    • Nasogastric tube (most common).

    • Nasoduodenal (ND) and nasojejunal (NJ) tubes.

  • Long-Term Feeding:

    • Ostomy feeding is a surgically created stoma delivering nutrition directly to the stomach or intestines.

Enteral Nutrition: Formulas

  • Standard Formulas:

    • Composed of complex carbohydrates, proteins, and fats, with or without added fiber. Include milk proteins (casein & whey), carbohydrate sources (e.g., maltodextrin, sucrose), and fats (e.g., canola, soybean oils).

  • Hydrolyzed Formulas:

    • Contain partially or fully hydrolyzed nutrients for patients with digestion and absorption impairments.

  • Calorie Concentration:

    • Formulas can vary:

    • Less concentrated (1.0 to 1.2 cal/mL).

    • Concentrated (1.5 to 2.0 cal/mL).

    • Nutrient density considerations are crucial for patient needs and hydration.

Enteral Nutrition: Delivery Methods

  • Methods Include:

    • Continuous: Sustained over a 24-hour period.

    • Cyclic: Over less than 24 hours.

    • Intermittent: Given as boluses throughout the day.

Enteral Nutrition: Potential Complications

  • Common Issues:

    • GI: nausea, vomiting, diarrhea, bloating.

    • Metabolic: hyperglycemia.

    • Respiratory risk: aspiration is the most severe potential complication.

Monitoring Enteral Nutrition

  • Key Areas to Monitor:

    • GI tolerance (adverse reactions).

    • Weight changes (gains/losses).

    • Residual volume management (monitoring decision).

Transitioning to Oral Diets

  • Goals:

    • Ensure adequate nutrition while encouraging an oral diet.

    • Use cyclic enteral feeds overnight to promote oral intake.

Parenteral Nutrition (PN)

  • Overview:

    • Developed in the 1960s, involves the infusion of a nutritionally complete formula into veins, serving patients with nonfunctional GI tracts.

    • High costs associated with PN due to complexity and risks.

Parenteral Nutrition: Composition

  • Components Include:

    • Complete spectrum of nutrients: protein, carbohydrates, fats, electrolytes, vitamins, and trace elements, all mixed in sterile water.

    • Delivery methods include:

    • Two-in-One Formula: dextrose and amino acids.

    • Three-in-One Formula: dextrose, amino acids, and lipids.

    • Total fat calculation: 10 kcal/g from fats, typically providing 20-30% of total calorie intake.

  • Protein Calculation:

    • 4 kcal/g, monitored through nitrogen balance studies.

  • Carbohydrate Calculation:

    • 3.4 kcal/g from dextrose monohydrate.

    • PPN limited to 10% dextrose and controlled infusion rates.

Parenteral Nutrition: Electrolytes and Vitamins

  • Standard Supplementation:

    • Multivitamin (MVI) includes essential vitamins (12-13) and trace elements (4-7).

    • Thiamin is essential to counteract refeeding syndrome.

  • Medications Added May Include:

    • Insulin and Heparin targeted at preventing complications.

Parenteral Nutrition: Administration

  • Methods:

    • Continuous administration via a pump.

    • Cyclic feeding adjustments for managing blood glucose levels (both hypo and hyperglycemia).

  • Initial Feeding Protocol:

    • Slow initiation to prevent refeeding syndrome complications.

Refeeding Syndrome

  • Definition:

    • A condition caused by aggressively introducing parenteral nutrition to severely malnourished patients, leading to adverse metabolic responses.

  • Mechanisms:

    • Rapid feeding increases insulin levels.

    • Electrolyte shifts due to glucose metabolism can cause imbalances, leading to fluid retention.

  • Symptoms:

    • Edema, cardiac arrhythmias, muscle weakness, confusion, potential thiamin deficiency.

  • High-Risk Populations Include:

    • Severely malnourished individuals, including those with anorexia, acute weight loss, cancer, or significant alcohol usage.

  • Prevention Strategies:

    • Administer PN slowly; ensure electrolyte status is optimized before initiation; add thiamin.

Parenteral Nutrition: Complications

  • Complications Include:

    • Refeeding syndrome as a fluid and electrolyte imbalance risk.

    • Infection risks associated with central venous catheters.

    • Metabolic issues such as hyperglycemia, hypoglycemia, hypertriglyceridemia, and fluid abnormalities.

    • Hepatic complications leading to fatty liver and biliary conditions such as cholestasis.


study guide:
Causes and Risk Factors for Malnutrition

Malnutrition is defined as a lack of sufficient nutrients in the body, which can be caused by not eating enough, not eating the right types of food, or an inability to utilize the food that is consumed.

  • Immediate Causes: These include inadequate intake and the body's inability to use nutrients due to malabsorption or disease.

  • Underlying Risk Factors:

    • Medical Factors: Being hospitalized, chronic illnesses (such as cancer, diabetes, and lung disease), dental problems, loss of taste or smell, unintentional weight loss, medication side effects, physical disability, and swallowing difficulties.

    • Lifestyle Factors: Loneliness, food insecurity, and a lack of knowledge regarding food, cooking, and nutrition.

    • Mental Health: Depression, anxiety, grief, cognitive decline, and eating disorders.

Malnutrition in the Hospital Setting

The sources identify three specific types of malnutrition related to the health care setting, which are categorized based on the presence and severity of inflammation:

  1. Starvation-related malnutrition: Chronic starvation without inflammation, such as in cases of anorexia nervosa or a lack of access to food.

  2. Chronic disease-related malnutrition: Inflammation that is chronic and of a mild to moderate degree, often seen with organ failure, pancreatic cancer, or rheumatoid arthritis.

  3. Acute disease or injury-related malnutrition: Severe, acute inflammation resulting from major infections, burns, trauma, or closed head injuries.

Adverse Outcomes and Diagnosis

Malnutrition in a healthcare setting leads to several adverse outcomes, including muscle wasting, immune suppression resulting in increased infection, and an increased risk of pressure injuries and impaired wound healing. Furthermore, it results in increased length of stay, higher readmission rates, and higher overall treatment costs.

To diagnose malnutrition, a patient must meet at least two of the following six criteria:

  • Weight loss over a specific period.

  • Inadequate intake over a specific period.

  • Loss of muscle mass.

  • Loss of body fat.

  • Fluid accumulation.

  • Reduced functional status.

Prevention and Hospital Diets

Malnutrition often happens in the hospital because approximately one-third of patients are already malnourished upon admission, and another third of well-nourished patients may become malnourished during a long stay if untreated.

Prevention and management involve the Nutrition Care Process, where nurses perform an initial malnutrition screening. If a risk is identified, a nutritionist creates a custom nutrition plan that includes:

  • Suggested caloric intake: Typically 25–30 cal/kg/day.

  • Adequate protein: 1.2–1.5 g/kg/day to restore lean body mass, increasing to 1.5–2.0 g/kg/day post-surgery.

The primary goal of a diet order is to be the least restrictive possible while still meeting the patient's needs. Specialized diets are used for specific clinical reasons:

  • Clear Liquid: Used before procedures like a colonoscopy or after gastric bypass; includes broth, tea, and some juices.

  • Full Liquid/Pureed: Used post-operatively or if a patient has impaired chewing or swallowing.

  • Modified Diets: These involve changing food texture or increasing/decreasing specific nutrients to manage a condition.

Nutrition Support: Enteral and Parenteral

Patients may require specialized nutrition support if they cannot meet their needs through a regular oral diet.

  • Enteral Nutrition (EN): Used for patients with a functioning GI tract who cannot eat enough.

    • Advantages: It is cheaper, maintains gut integrity, supports the immune system, and has fewer infection risks compared to parenteral nutrition.

    • Administration: Delivered via transnasal tubes (short-term, like NG, ND, or NJ tubes) or ostomy feedings (long-term, via a surgically created stoma).

    • Formulas: Include standard (complex molecules), hydrolyzed (for impaired digestion), and specialty formulas (e.g., high-fat for respiratory disease or electrolyte-modified for renal disease).

  • Parenteral Nutrition (PN): A life-saving but high-risk and expensive therapy for patients with a nonfunctional GI tract.

    • Administration: Infused directly into the veins as a hypertonic formula. It can be administered continuously over 24 hours or cyclically over a shorter period.

    • Composition: Contains dextrose, amino acids, lipids, electrolytes, vitamins, and trace elements.

Complications and Refeeding Syndrome

Refeeding syndrome is a serious complication caused by aggressive feeding (PN, EN, or oral) of a severely malnourished patient.

  • Signs/Symptoms: Rapid insulin spikes cause cells to pull electrolytes from the blood, leading to edema, cardiac arrhythmias, muscle weakness, and confusion.

  • Prevention: Administer feeding slowly, ensure electrolytes are balanced before starting, and provide thiamine.

Other complications associated with parenteral feedings include:

  • Infection risk.

  • Metabolic issues: Hyperglycemia, hypoglycemia, and hypertriglyceridemia.

  • Organ issues: Fatty liver (hepatic) and cholestasis (biliary).

  • Fluid abnormalities