Nutrition Care Process Quiz

COM 5005 Lecture 6: Nutrition Screening, Assessment, and Malnutrition

• Learning Objectives:
  • Recall health trends in nutritional status of US population
  • List nutrition screening tools used in various settings
  • Define the Nutrition Care Process
  • Identify components of nutritional assessment
  • Define malnutrition and differentiate between classifications
• Session Outline:
  • Nutrition screening: Identifying nutritional risk, nutrition risk factors, screening tools and resources for practice
  • Nutrition assessment: Components of nutritional assessment, Physical exam and hallmark findings, assessment tools and resources for practice
  • Nutrition diagnosis: Forms of malnutrition, classification and communication about malnutrition, applications in patient care
• Why Does Nutrition Matter?:
  • Case studies presented:
    • 56-year-old worker: BMI 28, diabetes, HTN, moderate activity
    • 16-year-old soccer player: BMI 18, vegan, no PMH, elite competitor
    • 70-year-old accountant: BMI 24, smoker, limited activity
  • Research findings on US health (1990-2016):
    • Health improved overall from 1990-2016
    • Specific risk factors (drug use, high BMI, alcohol use) correlated with adverse outcomes in some states
    • Probability of death between ages 20-55 increased >10% in 5 states from 1990-2016
• Health Trends:
  • US spent $4.255 trillion on healthcare in 2021, with varying expenditure in different healthcare areas— hospital care, physician services, clinical services, etc.
  • Global nutrition targets progress:
    • Some trends are "on course" such as childhood stunting, childhood wasting, child overweight and obesity.
    • Other trends such as anemia, sodium intake, and raised blood pressure are "off course" or "no progress"

Terminology

• Nutrition Status:
  • State of the body related to consumption and utilization of nutrients
  • Reflects nutrient stores, excess or deficient nutrient intake, individual needs, utilization and demand
• Nutrition Screening:
  • Steps towards risk identification of patients, clients or groups who could benefit from nutrition assessment and intervention
• Nutrition Assessment:
  • Systematic process of obtaining, verifying, and interpreting data to understand nutrition-related problems.

Nutrition Risk Factors

• Age: Elderly and children
• Altered nutrition needs: Pregnancy, lactation, adolescents
• Socioeconomic factors
• Unintended weight loss >10% in 6 months
• 85% usual body weight
• Impaired nutrient digestion, absorption, utilization
• Altered metabolic conditions: Critical illness, cancer, diabetes

Nutrition Care Process

• Four interconnected steps:
  • Screening: Evaluate nutritional indicators, Physical exam, Intake history
  • Assessment: Describe the problem with standard terminology
  • Diagnosis: Monitoring and evaluation - check understanding, measure outcomes, reassessment
  • Intervention: Individual care plans, counseling, nutrition education

Nutrition Care Algorithm

• Flowchart detailing the process of nutrition care in patients
  • Admission, patient screening (at risk/not at risk), periodic re-screening, Development and implementation of Nutrition care plan, patient monitoring, Change in Status, Patient Goals achieved, termination of therapy, discharge planning

Nutrition Screening Tools

• Malnutrition Universal Screening Tool (MUST)
• Nutrition Risk Screening (NRS-2000)
• DETERMINE Checklist, Mini Nutrition Assessment (MNA)
• Subjective Global Assessment (SGA)

Sample Tools

• Mini Nutrition Assessment (MNA): Tool to assess risk of malnutrition in older adults; Includes questions on food intake, weight loss, mobility, psychological stress, and body mass index
• Subjective Global Assessment (SGA): Tool that assesses nutrition status based on patient history in order to identify problems related to consumption and utilization of nutrients.
• Twenty-Four-Hour Recall: Tool to collect detailed info on daily food and drink consumption
• Food Record/Food Diary: Tool allowing patients to track food/nutrient intake over a specific time frame (generally 3 days)

Assessment: Key Components

• Patient History
• Anthropometrics
• Biochemical Data
• Clinical/Nutrition-Focused Physical Exam
• Functional Assessment

Anthropometrics

• Height/Stature, Weight, Arm span, knee height & length
• Balance beam and electronic scales
• Use of growth charts for children and adults to track growth, weight-for-height, and BMI over time.
• Consideration of amputation and use of adjusted body weight measurements
• Details of skinfold measurements
• Using BIA for body composition assessment (not applicable in certain circumstances)
• Use of InBody Scanner for body composition

Biochemical Medical Tests

• Measurement of nutritional markers and indicators found in blood, urine, feces, and tissue samples
  • Hematological measures as markers of general health
  • Protein assessment
  • Immunocompetence
  • Inflammation Markers
  • Vitamin and mineral assessment
  • Different panels included Chem-7 and Chem-20

Biochemical Indicators

• Details on different chemical panels (Chem-7 and Chem-20)
• Immunocompetence evaluation
• Explanation about Total Lymphocyte Count (TLC)

Biochemical: Somatic Protein Status

• Creatinine height index as a tool to assess somatic protein status.

Biochemical: Micronutrient Status

• Laboratory tests available for vitamins & mineral status
• Specific conditions where micronutrient tests are important (e.g. IBS, osteoporosis, renal disease, alcohol use, vegan dietary patterns)

Clinical/Nutrition-Focused Physical Examination (NFPE)

• Systematic head-to-toe assessment considering factors such as insufficient energy intake, weight loss, muscle loss, subcutaneous fat loss, localized/generalized fluid accumulation, and decreased functional status.
• Includes specific assessment examples of face, temples, arms, and other regions showing signs/symptoms of malnutrition

Facial Features & Physical Assessment

• Pictures examples of different levels of malnutrition in facial features (Normal, Mild-Moderate and Severe)
• Physical exam measures including muscle loss in the temples, fat loss around the eyes and between triceps and mid-arm circumference.

Causes of Malnutrition

• Primary malnutrition can be explained as frank inadequate nutrient intake.
• Secondary malnutrition can be caused by malabsorption, impaired utilization or storage, excessive nutrient loss, and increased nutrient needs.

Etiology-Based Malnutrition Definitions

• Primary: Frank inadequate nutrient intake below needs with no concurrent pathology (such as self-restricted eating, famine, global issues)
• Secondary: Result from contributing factors (such as malabsorption, impaired utilization, excessive nutrient loss, or increased needs)

Malnutrition Severity Assessment

• Two factors needed for a diagnosis of malnutrition.
• Different severities based on factors such as energy intake, weight loss, body fat loss, muscle mass, edema, and grip strength; based on acute/chronic illness and social/environmental factors

Classic Malnutrition: Kwashiorkor

• Severe protein deficiency syndrome
• Characterized by dramatic loss of protein, risk of infections, protruding belly, edema, fatty liver, ascites, "flaky paint" skin lesion, and linear depigmentation of the hair (flag sign)

Classic Malnutrition: Marasmus

• Protein-calorie malnutrition syndrome.
• Characterized by somatic muscle wasting, hanging skin, body weight reduction, low subcutaneous fat, lipofuscin pigment, no edema, relatively normal serum albumin, pulse, BP, and temperature, increased risk of infection, and intellectual deficits.

Global Leadership Initiative on Malnutrition (GLIM) 2019

• A sample tool/framework for classifying and assessing malnutrition in diverse clinical settings.
• Includes phenotypic and etiological criteria and severity grades for assessing malnutrition.

Summary Points

• Various factors increase risk of malnutrition
• Nutrition screening is an important professional best practice
• Nutrition assessment involves teamwork, critical thinking and understanding/evaluating the disease process, evidence-based practice, documentation, and monitoring/evaluation.
• Malnutrition is an inadequate balance between dietary intake and individual/patient need.