Potential Etiologies Associated With Malnutrition In Illness PDF

# Potential Etiologies Associated with Malnutrition in Illness - Inadequate - Famine - Dietary Poverty - Chronic - Malnourished nutrition - Learning - Micronutrient - Poor - Nutritional Insulin - Leptin - Undernourishment - Obesity - Country - Deaths - Energy - Person - Home - Mortal # The Need...

# Potential Etiologies Associated with Malnutrition in Illness - Inadequate - Famine - Dietary Poverty - Chronic - Malnourished nutrition - Learning - Micronutrient - Poor - Nutritional Insulin - Leptin - Undernourishment - Obesity - Country - Deaths - Energy - Person - Home - Mortal # The Need for Guidelines in Nutrition Support - Making good choices about one's diet is not just an important way to reduce the risk of the onset of chronic conditions and maintain health. - Nutrition has a key part to play in the management of chronic condition and health outcome, as well as, in secondary prevention of multimorbidity. # Appropriate Nutrition and Eating the Right Kinds of Foods Can Lead to: - Prevent certain symptoms. - Delay the onset of complications. - Improve health outcomes for some patients. - Improve well-being and physical strength. # Whereas Poor Nutrition Can Lead to: - Reduced immunity. - Impaired physical ability. - Delayed recovery. # Depending on a Patient's Condition, Treatment, Lifestyle, Ability, Age and Environment, Certain Foods Will Be More Appropriate for Some Patients. - In these cases, nutrition should be adapted according to the patient's needs and status. This is very relevant when a disease affects taste, often as a side-effect of the use of medication. # Caregivers Together With Healthcare Professionals (and Patients if Can) Must Be Involved in Decisions Taken, Regarding the Need for Nutritional Assistance as Well as Medical Nutrition Care. - To maximize positive outcomes and to ensure patient safety, healthcare professionals who are experts in this area should make recommendations about initiating, monitoring and termination of medical nutrition care. ## Core Members Can Include Doctors, Dietitians, Nurses, and Pharmacists - Healthcare professionals should use evidence-based guidelines to assist them in selecting the most appropriate method of nutritional support for their patient, taking account of a wide variety of factors including: - The goals of care. - Patient's nutritional needs. - Ability to take, digest, absorb, metabolize, or excrete foods, nutrients or metabolites. - Diagnosis and Prognosis. - Patient's ability to adhere to the intervention. - Patient safety. - Patient reported outcome measures. - A patient with a poor appetite may not be able or willing to consume food or may lack the energy or ability to prepare it. - A patient who has lost the ability to swallow may need enteral nutrition (via the stomach) and a patient with intestinal obstruction may need parenteral nutrition (via the vein). - Similarly, financial aspects such as adequate equipment to prepare food and/or cost of concentrate food should not be ignored. # Malnutrition - It is a "state in which a deficiency of energy, protein and/or other nutrients causes measurable adverse effects on tissue/body form, composition, function or clinical outcome". ## Malnutrition is Both a Cause and a Consequence of Ill-Health and is Common in the Most Patients. - Since malnutrition increases a patient's vulnerability to ill-health. - Providing nutrition support to patients with malnutrition should improve outcomes but decisions on the most effective and safe means to do so are complex. - Guidelines are therefore needed to emphasize the following: ## 1- Malnutrition is Common. - Many people who are unwell in hospital or the community, are likely to eat and drink less than they need. This impairment of food and fluid intake may be short-lived as part of an acute illness, or prolonged if there are chronic medical or social problems. - If impaired food intake persists for even a few days, a patient can become malnourished to a degree that may impair recovery or precipitate other medical problems. - This is especially true if the patient was malnourished before they became unwell due to other longstanding medical or psycho-social problems, or a generally poor diet. - Many patients have no help with obtaining or preparing meals when they are ill at home, while those in hospital may have further problems relating to poor standards of catering, inappropriate mealtimes, and inappropriate eating aids and/or staff to help them eat and drink. ## 2- Malnutrition Increases Vulnerability to Ill Health. - The consequences of malnutrition include vulnerability to infections, delayed wound healing, impaired function of heart and lungs, muscle weakness and depression. - As a consequence, people who are malnourished go to hospital more often for longer periods and have higher complications and mortality rates for similar conditions. - If poor dietary intake persists for weeks, the resulting malnutrition may be life-threatening in itself. ## 3- Decisions on Providing Nutrition Support Are Complex. - Although it is clear that clinical outcomes in malnourished groups are poor compared to the better nourished (e.g. malnourished surgical patients have complication rates 2-3 times higher than their better nourished cases). - The indications for active nutrition support using dietary supplementation, enteral tube feeding, or parenteral nutrition are questionable. - When individuals are unable or unlikely to meet the majority of their nutrient needs for prolonged periods (e.g. patients with dysphagia or intestinal failure) the need for appropriate support is necessary. - However, if the likely period of impaired intake is uncertain, decisions on providing nutrition support and the best means to do so are more difficult with multiple criteria for choosing oral, enteral or parenteral modalities which vary with both individual patient needs and the clinical expertise available to ensure that any intervention can be undertaken safely. ## 4- Understanding of Malnutrition and Nutrition Support Amongst Many Healthcare Professionals May Be Poor - The many difficulties relating to the need and best approach of nutrition support are combined by a lack of knowledge about malnutrition and its treatment amongst many healthcare professionals. - There has been little emphasis on nutrition education in either undergraduate medical or nursing courses. - This has led to poor recognition of both nutritional risks and the dangers of poorly managed nutrition support. # Causes of Under-Nutrition in Patients - Most patients have an average food intake that is less than recommended and continue to lose weight while in hospital. Malnourished patients become careless and depressed. They have decreased appetite and less ability to eat. - The causes of disease-related under-nutrition are numerous, ranging from individual to systemic factors. - Under-nutrition and acute rapid weight loss of as little as 2-3 kg (5%) in combination with disease could be resulted in: - Increases the risk of complications. - Lowers resistance to infection. - Impairs physical and mental functioning. - Delays recovery. - May be life-threatening. # The Main Causes of Malnutrition Can Be Categorized Under the Following Headings: - Loss of appetite due to the disease. - Difficulties in chewing or swallowing. - Lack of assistance with feeding. - Inappropriate utensils. - Impaired cognitive function. - Missed meals due to interruptions or investigations at mealtimes or excessive fasting. - Inadequate provision of food and physical disability can cause under-nutrition or aggravate an existing deficiency. # Table-Causes of Disease-Related Under-Nutrition | CATEGORY | CAUSE | EXAMPLES | |---|---|---| | Reduced food intake | Anorexia | Poor appetite, nausea and vomiting as a result of disease process, treatment or depression | | | Change in taste and smell | Due to treatment or medication | | | Episodes of fasting | Before investigative procedures or operations; missed meals due to these procedures, or avoidance of food due to diarrhoea | | | Pain on eating | Sore mouth due to disease or partial gastrointestinal obstruction | | | Difficulties in chewing and swallowing | Dysphagia (e.g. due to stroke or dementia), ill-fitting dentures, poor oral health | | | Inability to eat independently | Physical handicap, arthritis, dementia | | | Respiratory problems | Pulmonary disease | | Mal-absorption | Impaired digestion | Pancreatic insufficiency, enzyme deficiencies (e.g. cystic fibrosis) | | | Impaired absorption | Intestinal resection (short bowel syndrome), mucosal damage (e.g. inflammatory bowel disease) | | | Excess losses from the gut | High output fistulae, protein-losing enteropathy, short bowel syndrome.| | Modified metabolism | Metabolic response to disease | Malignancy, trauma, chronic sepsis, multiple organ failure, advanced HIV infection | | | Metabolic consequences of impaired organ function | Renal disease, liver disease, pulmonary disease | # However, Not All Cases of Undernutrition Call for Aggressive Nutritional Support; in Some Cases, May Be of Little Benefit and Even Harmful. - Therefore, NCP should thus be performed, taking into consideration both the nutritional status and the severity of disease, and ordinary food should be the primary feeding choice. # The Objective of These Guidelines is 1. To improve the practice of nutrition support by providing guidance to assist all healthcare professionals to correctly identify patients in hospital or the community who require nutritional intervention. 2. To help them choose and deliver the most appropriate form of nutrition support at the appropriate time. 3. To improve people's quality of life by making them feel better through adequate nutrition. # Choosing a Feeding Method Guidelines 1. Ordinary food is the first choice to correct or prevent under-nutrition in both the in- or out- hospital patients. 2. Only when ordinary food or nutritional feeds do not meet the nutritional requirements of the patient, artificial nutritional support should be considered. 3. Nutritional feeds must not be used as a substitute for the adequate provision of ordinary food and must only be used where there are clear clinical indications. # Nutrition Role in the Management of Certain Chronic Conditions - Examples provide disease-specific explanations of the important role that nutrition plays in the management of certain chronic conditions. ## Cancer - Patients with cancer are at a particularly high risk of malnutrition because both the disease and its treatments threaten their nutrition status. - Cancer-related nutritional risk is sometimes overlooked or under-treated by clinicians, patients, and their families. - Depending on the type of cancer and stage of treatment, guidance can differ. - Additionally, cancer patients' taste and ability to eat can also be significantly affected. - Sometimes disease conditions malnutrition, due to lack of appetite, problems in swallowing, increased catabolism or caused by treatment; known as "malnutrition related to the disease". - Ex., people with throat cancer can have serious swallowing problems. ## Diabetes - There are two main types of diabetes, type 1 and type 2. There are some other types of diabetes too, such as gestational diabetes. - Type 1 diabetes is a lifelong condition where the blood glucose level is too high because the body cannot make insulin hormone. - In Type 2 diabetes the blood glucose level is too high because the body does not produce enough insulin, or the body cannot effectively use the insulin it produces. - Insulin allows the glucose in the blood to enter cells and fuel our bodies. - Over a long period of time, high glucose levels in the blood can seriously damage the heart, veins and arteries, eyes, neurological complications, feet and kidneys. These are known as complications of diabetes. - A key requirement in preventing complications is maintaining good blood glucose (glycemic) control, blood pressure and cholesterol level. - Comprehensive nutritional information, education and training is vital for people with diabetes to be able to adequately manage their condition. - This may include: - Calculating the amount of carbohydrates and calories. - Recognizing hidden sugar within food ingredients. - Knowing the amount of salt and fats in the food. - Weight control. ## Allergy - The western lifestyle with changing nutrition, gut flora, air pollution, chemicals and processed food have been studied a lot in connection with the development of allergy. - For food allergy, the only treatment is avoidance. - People and families with food allergy rely on food labelling. - For some people with food allergy their diet is so restrictive that food supplements are needed to ensure good nutrition. - Management of food allergy always requires a mandatory nutritional guidance by a dietician or other healthcare professional. - Severe food allergy can be highly limiting for patients and families and requires education of all actors in the food chain, including schools, catering, and restaurants. ## Chronic Kidney Disease - Patients can require a kidney diet to prevent more kidney damage. - People living with chronic kidney disease may need to limit fluids, eat a low protein diet, limit salt, potassium, phosphorus and other electrolytes. - This can prevent certain minerals building up in the body. Therefore, they may need food supplements. ## Cardiovascular Disease - Consumption of long chain omega 3 polyunsaturated fatty acids, fish, fruit and vegetables, nuts, fibre and replacing saturated fats with polyunsaturated fatty acids are associated with beneficial heart effects. - While consumption of saturated fatty acids, trans fatty acids and salt are associated with an increased risk of cardiovascular events. - Mediterranean dietary pattern is often recommended. ## Inflammatory Bowel Disease (IBD) - Malnutrition is highly prevalent in IBD, especially in Crohn's disease and ulcerative colitis (the common factors have been suggested to be at cause). - These patients may need medical nutrition in different phases throughout their lives, especially during the acute phase of their disease. ## Chronic Intestinal Failure (CIF) - The CIF is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes. - Intravenous supplementation is required to maintain health and/or growth. - Even though it is very important that these patients maintain some ingestion of food and nutrients adapted to the characteristic of their intestine, they depend on parenteral nutrition to support their life. # Association Between Nutritional Status and Length of Hospital Stay - The length of hospital stays, and the treatment are directly affected and influenced by the patient's nutritional status. - Although the reported prevalence of hospital-associated malnutrition varies greatly depending on practice and assessment instrument, the association between malnutrition and length of stay is consistent and has always been confirmed by studies. - The hospital is the best-prepared place to provide patient care; it is where highly complex treatments and life support can be found when life is at risk. - Longer hospital stays can be avoided thorough screening and monitoring of the patient's nutritional status, along with early introduction of nutritional therapy to correct existing deficiencies. This done by applying the NCP steps. - This measure is not taken very often, but its need is recognized. - A longer-than-necessary hospital stay does not satisfy the patient or the health-care team and increases costs, whether public or private. Also, hospital stay itself is a risk factor for infection, other health hazards, and the patient's well-being. - The factors that influence length of stay basically have a universal character and involve the treatment proposed. - The nutritional status of hospitalized patients is often poor on admission and continues to deteriorate during their stay. - In general, clinical and surgical patients are exposed to many risk factors that promote hospital-associated malnutrition. - Such as changes in the digestive tract, inadequate nutrient and energy intakes, the long fasting periods imposed before and after surgery and other complications related to gastrointestinal surgeries, and other factors associated with the clinical course of the illness. - Nobody questions the fact that a well-nourished body responds better to treatment, but evidencing this fact is not so easy because the relationship between nutritional status and disease is very complex. ## Applications to Critical or Intensive Care - Intensive care patients are more vulnerable to malnutrition because of their usually higher metabolic requirements, frequent food intake difficulty or inability, and often abnormal metabolic and hemodynamic functions. - These factors place critical care patients at high risk of malnutrition and make them possible candidates for aggressive nutritional interventions. ## Applications to Other Conditions - Poor nutritional status always affects response to treatment in a negative way, resulting in longer hospital stays. - The prevalence of malnutrition varies greatly but that it is always present. - Concurrently, longer hospital stays always associated with malnutrition, regardless of the assessment tool used or the characteristics of the target population.