anjelice foreman rdn food and nutrition services

Image source: http://www.ultramarathonman.com/web/about/diet.shtml

Anjelice Foreman RDNFood and Nutrition Services

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None of the faculty, planners, speakers, providers, nor CME committee members have any relevant financial relationships with commercial interests.

There is no commercial support for this CME activity.

OBJECTIVES.

• Determine the importance of nutrition

• Define Malnutrition

• Define Clinical characteristics to support the diagnosis of

malnutrition in adults

• Define Nutrition Focused Physical Exam

• Appropriate supplementation with malnutrition

“The only way to keep your health is to eat what you don’t want, drink

what you don’t like, and do what you’d rather not.”

-Mark Twain

nutrition1

noun | nu·tri·tion | nü-’tri-shen

1: the act or process of nourishing or being nourished; specifically: the sum of the processes by which an animal or plant takes in and utilizes food substances

Why is nutrition important?2

Nutrition is essential for our bodies to: Produce energy to stay warm, move, work Develop, replace, and repair cells and tissues Carry out chemical processes such as the digestion of

food Protect against, resist and fight infections and recover

from illness

Micronutrients (vitamins, minerals) are needed in small amounts

Macronutrients (carbohydrates, protein, fat) are needed in larger amounts

Image source: http://www.bu.edu/summer/courses/nutrition/

Water Soluble• Vitamin C• Vitamin B

- Thiamine - Riboflavin- Niacin - Pantothenic acid- Biotin - B-6- B-12 - Folate

Fat Soluble• Vitamin A• Vitamin D• Vitamin E• Vitamin K

Macrominerals• Calcium• Phosphorus• Magnesium• Sodium• Potassium• Chloride• Sulfur

Trace minerals• Iron• Manganese• Copper• Iodine• Zinc• Cobalt• Fluoride• Selenium

MINERALS4VITAMINS3

MICROELEMENTS.

Micronutrients or microelements, also known as vitamins and minerals, are vital to development and disease prevention2

Defined by the World Health Organization (WHO)

• ‘Undernutrition’

• Stunting (low height for age)

• Underweight (low weight for ht)

• Micronutrient deficiencies (a lack

of important vitamins & minerals).

• Overweight, Obesity and Diet-Related

Non-communicable diseases

• Heart disease

• Stroke

• Diabetes

• Cancer

MALNUTRITION5

Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients. The term malnutrition covers 2 broad groups of conditions.

Inadequate intake of protein and/or energy over prolonged periods of time resulting in loss of fat stores and/or muscle

wasting.

Signs & Symptoms (one or more must be

present): Physical signs

• Loss of subcutaneous fat

• Muscle loss

• Localized or generalized fluid accumulation

• Change in functional indicators (hand-grip strength)

• Weight loss (Malnutrition can occur at any weight/BMI)

BMI <18.5 for adults indicates underweight (BMI <22 for adults

older than 65 yrs)

Unintentional weight loss in adults

MALNUTRITION6

.


wasting.

BMI (kg/M2) Interpretation

<18.5 Underweight

18.5 - 24.9 Normal

25 – 29.9 Overweight

30 – 34.9 Obesity (Class 1)

35 – 39.9 Obesity (Class 2)

≥40 Extreme Obesity (Class 3)

MALNUTRITION6

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wasting.


present):

Unintentional weight loss in adults

>10% in 6 months

>7.5% in 3 months

>5% in 1 month

>1-2% in 1 week

Considerations:

Measurements vs estimations

Fluid status (dehydrated vs edematous)

Scale variation

Clothes/shoes

MALNUTRITION6

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wasting.


present):

Intake

• Estimated energy intake <50-75% of estimated or measured resting metabolic rate (RMR)

• Estimated intake of high-quality protein less than estimated requirements

• Food avoidance and/or lack of interest in food

• Excessive consumption of alcohol or other drugs that reduce appetite

Other

• Chronic disease (DM, chronic pancreatitis, IBD, celiac disease, sarcopenic obesity, cancer,

organ failure)

• Acute disease (Major infections, burns, trauma, head injury)

• Severe protein and/or nutrient malabsorption

• Reports of anorexia, benign esophageal stricture

• Reports of abuse, neglect, poverty, frailty, or anything that results in limited access to food

(associated with malnutrition in the context of environmental and social circumstances)

MALNUTRITION6

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3 Categories of Malnutrition

Starvation related

Pure Chronic Starvation

Anorexia Nervosa

Chronic Disease related

Organ Failure

Pancreatic Cancer

Rheumatoid Arthritis

Sarcopenic Obesity

Acute Disease or Injury related

Major Infection

Burns

Trauma

Closed Head Injury

MALNUTRITION6

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Clinical CharacteristicsThat the Registered Dietitian (RD),

Can Use to Support the

Diagnosis of

Malnutritionin Adults

Physical Signs of Malnutrition6

Fat Loss: Regions

• Orbital Region

Temporal bone Zygomatic arch

• Upper Arm Region

Biceps Triceps

• Thoracic and Lumbar Region

Ribs Lower back

Fat Loss: Orbital Region

Exam: loss of fat under the eyes visually and touch below eyes to assess

Findings:

• Severe loss

Pronounced hollowness/depression

• Moderate loss

Slight hollowness, dark circles

• No loss

Slight bulging


Fat Loss: Upper Arm Region

Exam:

Bend arm 90 degrees, pinch arm at midpoint and roll down until free of

muscle & only pinching fat

Findings:

• Severe loss

Mostly skin

• Moderate loss

Some fat tissue, not ample

• No loss

Ample fat tissue


Fat Loss: Thoracic & Lumbar Region

Exam:

Visually examine lower back and mid-axillary line. Physically examine fat

stores iliac crest.

Findings:

• Severe loss

Ribs visible with prominent depressions, iliac crest prominent

• Moderate loss

Ribs visible with mild depressions, iliac crest prominent

• No loss

Chest is full, ribs not visible, iliac crest with little to no protrusion


Fat Loss

• Fat loss is more prominent in the upper body

• Fat loss may be seen visually but physical examination allows quantified

results to verify visual findings.

• Confirm with patient that fat loss is not normal for them


Muscle Loss: Regions

• Temple region

• Clavicle Bone Region

Pectoralis Major, Deltoids,

Trapezius

• Scapular Bone region

Latissimus Dorsi

Trapezius

Supraspinatus

Infraspinatus

• Dorsal Hand Region

• Patellar Region

• Anterior Thigh Region

Quadriceps

• Posterior Calf Region

Gastrocnemius


Muscle Loss: Temple Region

Exam:

Observe from front and side, touch temples in a cross-type motion, have

patient bite down.

Findings:

• Severe loss

Hollowing/scooping/depression

• Moderate loss

Slight depression

• No loss

Can see and feel muscle. May appear flat or bulged


Muscle Loss: Clavicle Bone Region

Exam:

Have patient sit up straight, visually examine bone, physically examine

surrounding muscle.

• Severe loss

Protruding, prominent bone

• Moderate loss

Some protrusion, bone visible

• No loss

Bone visible, not prominent, bone not visible (in obese patient)


Muscle Loss: Clavicle Bone Region: Deltoid

Exam:

Patients arms are at their sides, sitting or standing

• Severe loss

Squared shoulders, bones & acromion process prominently protruding

• Moderate loss

Acromion may protrude slightly, some shoulder angling

• No loss

Rounded shoulders & curves at neck


Muscle Loss: Scapular Bone Region

Exam:

Patients arms extended straight out, pressing against solid object, sitting or

standing

• Severe loss

Prominent bones, depressions easily visible between ribs, scapula, spine, shoulders

• Moderate loss

Mild depressions, bones showing slightly

• No loss

Bones not prominent with no significant depressions


Muscle Loss: Dorsal Hand Region

Exam:

Having patient make an “OK” sign and feel for musculature. Relaxing hand

also look for depressions on back of hand.

• Severe loss

Prominent depression

• Moderate loss

Slight depression

• No loss

No depression


Muscle Loss: Patellar Region

Exam:

Examine with bent knee

• Severe loss

Prominent bone, squared, very little muscle definition around patella

• Moderate loss

Patella less prominent, low muscle definition around patella

• No loss

Muscles protrude around patella, difficult to see bone


Muscle Loss: Anterior Thigh Region

Exam:


• Severe loss

Depression along thigh, thin

• Moderate loss

Mild depression of inner thigh

• No loss

Muscles protrude, bone not visible


Muscle Loss: Posterior Calf Region

Exam:


• Severe loss

Thin with very little firmness

• Moderate loss

Slight firmness

• No loss

Well-rounded, firm, well developed muscle


Fluid Accumulation

Pitting edemaApply pressure to a bony prominence for ~5 seconds, release and examine for remaining indentation

Edema Grade Description Malnutrition Classification

1+ Barely detectable Mild

2+ Slight indentation15 second rebound

Moderate

3+ Deeper indentation 30 second rebound

Severe

4+ Deep indentation>30 seconds to rebound

Severe


Fluid Accumulation

Non-pitting edema• Firm & tight skin that does not depress when pressure is applied

Dehydration• Skin Turgor (tenting)

• Pinch skin on back of hand or forearm. Skin should return to normal position within 3 seconds

• Capillary Refill• Press fingernail until white, release and examine color. Color should return

within 3 seconds


Hand Grip Strength

• Measure of muscle functionality

• Only performance measure recommended for use in nutritional assessment

• Decreased with poor protein intake and decreased musculature

• Dynamometers used according to manufacturers guidelines (values may vary by

manufacturer)

• Take 3 measurements and average

• Dominant vs Non-dominant hand


Identification of Malnutrition6

Malnutrition in the Context of Acute Illness or Injury

Malnutrition in the Context of Chronic Illness

Malnutrition in the Context of Social or Economic

Circumstances

Clinical Characteristics

NonsevereMalnutrition

Severe Malnutrition


Severe Malnutrition


Severe Malnutrition

Energy Intake(estimated)

<75% of energy requirement for

>7 days

≤50% of energy requirement for

≥5 days


≥1 month


≥1 month


≥3 months

≤50% of energy requirement for 1

month

Weight Loss

% Time % Time % Time % Time % Time % Time

1-2% 1 week >2% 1 week 5% 1 mo >5% 1 mo 5% 1 mo >5% 1 mo

5% 1 mo >5% 1 mo 7.5% 3 mos >7.5% 3 mos 7.5% 3 mos >7.5% 3 mos

7.5% 3 mos >7.5% 3 mos 10% 6mos >10% 6 mos 10% 6 mos >10% 6 mos

Body Fat Mild Moderate Mild Severe Mild Severe

Muscle Mass Mild Moderate Mild Severe Mild Severe

Fluid Accumulation Mild

Moderate to severe Mild Severe Mild Severe

Grip Strength N/A Not recommendedin ICU

N/A Measurablyreduced

N/A Measurably reduced

Why isn’t albumin used as an indicator of malnutrition?

Albumin.

• Albumin can be altered by factors such as fluid imbalance, liver or renal disease, infection, antibiotics, metabolic stress, and surgery, all of which are common in the inpatient setting.

• Prealbumin is a more specific indicator of nutritional depletion and repletion since it is less affected by liver disease, renal disease, critical illness, and fluid status, and it is more sensitive due to its short 2-day half-life, very small body pool (100-fold smaller than albumin), and high ratio of essential to nonessential amino acids.

• Although prealbumin may be a better indicator than albumin it is recommend to rely more on the physical findings of malnutrition, previously discussed.

SUPPLEMENTS7

. Ensure Clear: on clear-liquid or post-surgical and is suitable for lactose intolerance. Contains milk protein – not appropriate for milk allergies

Ensure Enlive: One simple choice for balanced nutrition and targeted muscle, heart, immune system and bone support. Similar to a milkshake. Suitable for lactose intolerance.

Ensure pudding: For patients on consistency-modified diets (eg, soft, puree, or full liquid). Suitable for lactose intolerance. Honey thick at room temperature.

Glucerna: A unique blend of carbohydrates, including slowly digestible carbohydrate clinically shown to help minimize blood glucose response

Nepro: Therapeutic nutrition specifically designed to help meet the nutritional needs of patients on dialysis. Contains CARBSTEADY carbohydrate blend designed to help manage blood glucose response. Nectar thick at room temperature.

Suplena: Therapeutic nutrition specifically designed to help meet the nutritional needs of patients with Stage 3/4 chronic kidney disease/non-dialyzed. Contains CARBSTEADY. Nectar thick at room temperature.

Enteral Nutrition7.

Standard Formulas

Osmolite 1.2 Cal & 1.5 Cal: Intact, low-residue formula

Jevity 1.2 Cal & 1.5 Cal: Intact, high fiber formula

Specialty Formulas

Vital 1.2 Cal & Vital 1.5 Cal: Hydrolyzed, peptide-based formula. Helps manage inflammation and GI

intolerance.

Pivot 1.5 Cal: Hydrolyzed, peptide-based formula. For metabolically stressed surgical, trauma, burn, or head

& neck cancer patients, immune enhancement. Should not be used with septic patients.

Oxepa: Intact formula that helps modulate the inflammatory response in critically ill, ventilated patients

Diagnosed with ALI, ARDS, SIRS.

Nepro: Formulated for patients on dialysis. Concentrated (1.8 kcal/ml), low phosphorus/potassium/sodium

Higher protein content than Suplena.

Suplena: Formulated for patients with CKD. Concentrated (1.8 kcal/ml),

low phosphorus/potassium/sodium. Low protein content.

Case Study 1.

What immediate concerns are noted to be addressed by MD? Social worker?

Dietitian? Pharmacy?

80yo Hispanic male hx of DM, HTN, HLD, presents with GI bleed and C diff. Pt reports that

his wife died ~2 months ago and since has not been eating much. Now lives alone. ~2

weeks ago began having diarrhea that has now become blood tinged. Unable to state any

medications he has been taking and how frequently he has been taking them.

Patients family arrives and is able to give more history. Family reports <40% intake of meals

over the last 1-2 months. Daughter states that she lives near patient and visits multiple

times a week. Upon visit daughter notes that her father mostly eats “junk food” like

cookies, crackers, tortillas and beans as well as small amounts of the meals that she brings

him.

Case Study 1.

• Intake is <40% of meals over 1-2 months.• Likely not taking medications regularly.• BMI 22 • 2+ edema in upper and lower extremities• Overall appears very thin. • Protruding clavicles, depressed temples,

squared shoulders• Bicep and tricep area is mostly skin• Generalized weakness per pt

Labs

• Albumin 1.2g/dL• Mg 1.8 mg/dL• Phos 1.2 mg/dL• K 2.4 mmol/L• Na 142mmol/L

Labs are drawn, visual and physical assessments are performed.

Is this patient malnourished? If so what classification?

Case Study 1.

Following a diagnosis of severe malnutrition, what nutrition intervention could be recommended?

Begin PO diet with supplements, monitor labs for refeeding syndrome.

If unable to begin PO diet, consider initiating enteral nutrition if patient is agreeable.

If unable/patient not agreeable to enteral nutrition, begin parenteral nutrition.

How can other member of the healthcare team get involved?

Consult Social worker for referrals to Office on Aging, In Home Support Services and home health for medication management.

Psych consult for depression





Circumstances



Severe Malnutrition


Severe Malnutrition


Severe Malnutrition



>7 days


≥5 days


≥1 month


≥1 month


≥3 months


month

Weight Loss












Case Study 2.

• Reports 10lb weight loss in 1 month.• No edema. • BMI 21.3.• Bicep and tricep area has ample fat

tissue.• Temples with slight depressions• Slight acromion protrusion• Ribs and iliac crest with slight

protrusion/prominence

Labs

• Albumin 3.3 g/dL• Mg 1.3 mg/dL• Phos 2.7 mg/dL• K 3.8 mmol/L• Na 140mmol/L• A1c 11.5

Is this patient malnourished? If so what classification?

67 yo female Hx of DMII, HTN, CKD III and pelvic mass presents with N/V/D and poor PO intake x 4 days. UBW 58kg. Labs are drawn, visual and physical assessments are performed.

Case Study 2.

Following a diagnosis of moderate malnutrition what nutrition intervention could be recommended?

Initiate anti-emetic treatment. When N/V resolves, begin PO diet with supplements.

Which supplement would be appropriate for a patient with DM II, CKD III and HTN?

Suplena





Circumstances



Severe Malnutrition


Severe Malnutrition


Severe Malnutrition



>7 days


≥5 days


≥1 month


≥1 month


≥3 months


month

Weight Loss












Questions?

REFERENCES. 1. Nutrition. Merriam-Webster website. http://www.merriam-webster.com/dictionary/nutrition. Accessed August

9, 2017.

2. Corporate Document Repository. Food and Agriculture Organization of the United Nations website.

http://www.fao.org/docrep/005/y4168e/y4168e05.htm. Accessed August 9, 2017.

3. Vitamins. US National Library of Medicine MedlinePlus Website.

https://www.nlm.nih.gov/medlineplus/vitamins.html. Accessed August 9, 2017.

4. Minerals. US National Library of Medicine Medline Plus Website.

https://www.nlm.nih.gov/medlineplus/minerals.html. Accessed August 9, 2017.

5. What is Malnutrition. World Health Organization. http://www.who.int/features/qa/malnutrition/en/. Accessed

August 9, 2017.

6. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral

Nutrition. White JV, et al. http://journals.sagepub.com/doi/abs/10.1177/0148607112440285?url_ver=Z39.88-

2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&#articleCitationDownloadContainer.

Accessed August 9, 2017

7. Our products. Abbott Nutrition For Health Care Professionals. http://www.abbott.com/our-products/product-

list.html. Accessed August 9, 2017

Questions regarding this conference please contact:

Beverly JohnsonStaff Development Officer

Riverside County-DPSS [email protected]

951-413-5607

mailto:[email protected]

anjelice foreman rdn food and nutrition services

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