Chapter 52: Care of Patients with Malnutrition, Undernutrition, and Obesity

Key Concepts

• Primary Concept: Nutrition
• Secondary Concept: Fluid and Electrolyte Balance

Guides for Good Nutrition

• Dietary Reference Intakes (DRIs): Based on age, gender, and life stage
• Dietary Guidelines for Americans: Drafted by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services
• My Plate: Pictorial demonstration to build a healthy plate of food
• Canada Food Guide: Provides visual reference
• No universal diet; varies based on preferences and sensitivities

Types of Diets and Food Sensitivities

• Vegetarian Diets: Various types (Box 52.2)
• Food Sensitivities vs. Allergies:
  • Allergies: Immune inflammatory response (e.g., shellfish causing facial edema)
  • Intolerance: GI tract unable to break down certain foods (e.g., lactose, some raw vegetables)

Nutrition Assessment

• Nutrition History: Typical intake over a few days (ideal: 7 days, minimum: 72 hours)
• Access to Nutrition: Assess resources and ability to obtain nutritious food
• Labs: Fluid and electrolyte status, iron deficiency (anemia), albumin, prealbumin
• Medications: Check for food-drug interactions
• General Health History and Physical Assessment: Look for signs of nutritional deficits
• Anthropometric Measurements: Use calipers for adipose tissue
• Psychosocial Assessment: Relate to nutritional status
• Initial Screening: Within the first 24 hours of hospital admission
• Tools: Mini Nutritional Assessment, Adult Malnutrition Screening (Box 52.3)
• Measurements: Height, weight, BMI, body surface area (BSA), skin fold

Undernutrition Pathophysiology

• Protein Energy Malnutrition (PEM): Previously called Protein Calorie Malnutrition
  • Merasmus: Caloric malnutrition (body fat and protein wasted)
  • Kwashiorkor: Lack of protein quantity and quality (normal body weight)
  • Starvation: Severe caloric deficiency
• Eating Disorders: Anorexia nervosa, bulimia nervosa, binge eating disorder
  • Anorexia Nervosa: Not consuming needed nutrition
  • Bulimia Nervosa: Binge eating with purging

Assessing Older Adults

• Conditions and Illnesses: Affecting GI motility, appetite, dentition
• Medications: Impact on motility or appetite
• Oral Care: Dry mouth, oral hygiene
• Failure to Thrive: Failure to gain/maintain weight in older adults
• Psychosocial Factors: Ability to prepare meals, memory issues, depression, loneliness, resources

Health Promotion and Disease Prevention

• Statistics: 462 million malnourished worldwide
• Hospitalization: 1/3 develop malnutrition
• Nutrition Advocacy: Essential for healing

History and Assessment for Undernutrition

• Food Intake: Usual intake, meal timing, preferences, patterns
• Signs and Symptoms: Hair, eyes, oral cavity, nails, skin, musculoskeletal, neurological function
• Anthropometric Measurements: Subcutaneous fat, lean muscle
• Partnership with Dietitian: For caloric intake assessment

Psychosocial and Economic Factors

• Economic Status: Impact on ability to secure food
• Occupation and Education Level: Understanding of nutrition
• Living Arrangements: Emotional status and resources

Lab Assessments for Undernutrition

• Labs: Hemoglobin, hematocrit, transferrin, prealbumin, albumin, thyroxine-binding prealbumin, cholesterol

Plan for Undernourished Patients

• Goals: Improve nutrition
• Meal Management: Small, frequent meals, dietary supplements
• Drug Therapies: For motility issues, anti-emetics
• Enteral Nutrition: Gastric or enteral ostomy-feeding tubes (NG, OG, NJ, PEG)
• Types of Feeding: Bolus, continuous, cyclic
• Complications: Tube clogging, misplacement, nausea, vomiting, abdominal distention
• Fluid and Electrolyte Imbalances: Monitor labs
• Parenteral Nutrition: PPN via PIC, TPN via central line

Obesity Pathophysiology

• Definition: Overweight (BMI 25-29), Obesity (BMI ≥30)
• Factors: Environmental, genetic, behavioral, physical inactivity, medications
• Incidence and Prevalence: Doubled since 1980, 1/3 of world population
• Health Priorities: Healthy People 2030, weight management, physical activity

Nutritional Assessment for Obesity

• History: Use RESPECT acronym (rapport, privacy, realistic goals, compassion, tact)
• Appetite: Attitudes towards food, chronic diseases, medications
• Functional Ability and Physical Activity: Familial history, past weight loss attempts
• Anthropometric Measurements: Height, weight, skin fold areas
• Psychosocial Assessment: Emotional factors, perception of nutritional status

Management of Obesity

• Goals: Improve nutrition
• Non-Surgical: Diet programs, nutritional therapy, exercise, drug therapy (e.g., GLP-1 agonist, Ozempic)
• Surgical: Bariatric surgery (gastric banding, gastric bypass)
• Post-Op Management: Nutritional supplements, pureed to solid foods, multiple small meals, signs of dumping syndrome
• Community Resources: Registered dietitian, Overeaters Anonymous, American Society for Metabolic and Bariatric Surgery
• Evaluation: Appropriate nutrient intake, maintenance of weight, adequate hydration, infection-free post-surgery