Understanding Nutrition and Its Impact

Aug 9, 2024

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