Malnutrition and Obesity

1. What is malnutri- • A state in which a deficiency, excess or imbalance of tion? energy, protein and other nutrients causes measurable adverse effects on tissue/ body form, function or clinical outcome NICE states that malnutrition is shown by • A BMI (body mass index) of less than 18.5mg/m2 • Unintentional weight loss greater than 10% within the past 3-6 months • A BMI if less than 20kg/m2 and unintentional weight loss greater than 5% within the past 3-6 months 2. What is the scale • A study in 2010 found that more than 3 million people of malnutrition in in the UK are malnourished, of which 1.3 million are >65 the UK? years old • 1 in 10 people >65 years old are malnourished or at risk • People at risk of malnutrition include - 32% of people admitted to hospital - 35% of patients admitted to care homes - 10-14% of those in sheltered accommodation - 18-20% of patients admitted to mental health units • 70% of patients weigh less on discharge from hospital than on admission 3. What causes malnutrition? An inadequate intake of energy, protein and other nutrients, and this can be due to • The inability to eat/ drink anything, eg due to a lack of swallowing reflex, nil-by-mouth (where the patient has been advised to not eat anything eg if they have a procedure) • The inability to eat/ drink sufficient food to meet nutritional needs, eg due to chronic health conditions like malabsorption, lack of appetite, lack of availability of food • Self-imposed restriction of food/drink, eg being on an extreme weight-loss diet, eating disorders 4. What are costs associated with malnutrition? • Health and social care costs in the UK associated with malnutrition are estimated to be at least £19.6 billion per year, or atleast 15% of overall expenditure on health and 1 / 15 social care is related to malnutrition • This is because it impacts both primary and secondary care • In secondary care, malnutrition can lead to an increased incidence of complications, an increased length of hospital stay (around 3 days longer if you have malnutrition) an increased risk of readmission, and also increased mortality • In primary care, malnutrition can cause an increased dependency on healthcare services, an increased amount of GP visits (at least 2x more visits if you have malnutrition), increased prescription costs and increased visits/ admissions to hospital (around 3x more admissions if you have malnutrition) 5. What are the clinical consequences of malnutrition on individual patients? • Weight loss • An impaired immune response, leading to increased likelihood of infections • Reduced muscle strength and fatigue, leading to inactivity making the person less likely to work and practice self-care, poor cough reflex where there is muscle weakness in the chest, increased risk of falls, and heart failure • Impaired wound healing • Impaired psycho-social function, causing depression, self-neglect and less socialisation • Impaired recovery from surgery/illness, which can increase length of hospital stay • Specific nutrient deficiencies, leading to anaemia, scurvy, rickets, beri-beri • Reduced fertility • Additional problems in children and pregnancy 6. What are at-risk groups for malnutrition? • People >65 years, particularly whilst in hospital or recently discharged • Patients with chronic diseases, which could impair absorption, lead to confusion, reduce appetite. For example COPD, IBD, renal failure, dementia, cancer, dysphagia • People that abuse drugs or alcohol, as they focus on their addiction so are less likely to prioritise a healthy and balanced diet. They are also likely to have social 2 / 15 circumstances that could impact their nutrition • Those with mental health problems or a recent change in personal circumstances eg bereavement • People taking multiple medications, as the more medications taken, the increased likelihood of side effects eg reduced appetite • Residents in nursing/ residential homes • People with problems eating eg sore mouth, dysphagia, needing help to cut up food to be able to eat it • Immobile, housebound patients, who are unable to obtain a consistent amount of food that they need • Those living in poverty. 22% of people over the age of 60 years have admitted to missing meals to save money 7. What is the Malnutrition Universal Screening Tool (MUST)? • A simple, inexpensive tool that highly correlates to the medical diagnostic criteria for malnutrition • It is used widely in health settings • It is an objective way to allow for early identification of malnutrition, which enables prompt, individualised and appropriate advice and treatment 8. Why is screen- • It is not always apparent by looking at an individual to ing for malnutri- establish if they are malnourished tion necessary? • A lot of indicators for weight loss are subjective eg being thin/ very thin in appearance, wearing loose fitting clothing, dentures or jewellery, the patient mentioning that they have a history of recent unplanned weight loss. These indicators are not accurate in identifying malnutrition, and obesity/ being overweight can mask malnutrition • Therefore we need an objective measure like screening 9. When would you • Upon first contact with the patient eg when they first see screen patients a GP, when they are first admitted to hospital or a care for malnutrition? home • When a pharmacist is doing a medication review • If there are any clinical concerns with the patient that the healthcare professional has noticed eg unplanned weight loss, poor wound healing, pressure ulcers, prolonged illness 3 / 15 • If any concerns are highlighted during screening, the patient should be referred to a GP or a dietician. They will provide appropriate advice or supplementation according to the calculated risk shown by the MUST screening tool 10. What is the triangle for nutrition support (for use once the patient has been identified as being malnourished)? • A hierarchy of how nutrition is obtained in people: - Normal oral diet is at the bottom of the triangle - Fortified diet - Supplements - Nasogastric feeding - Jejunostomy and PEG feeding - Parenteral nutrition is at the top of the triangle • Enteral tube feeding eg nasogastric and PEG feeding, and parenteral nutrition are more invasive methods of nutritional support than oral nutrition supplements 11. What is a normal • Most people can meet their nutritional needs through oral diet? normal food and drink • Some patients may need support to carry on eating and drinking healthily eg the patient may have lost their appetite (due to age or illness) or they have a low mood, or they may be able to eat or drink normally but they are unable to cook or shop for themselves (due to being housebound or immobile) • For these patients, signposting is essential such as the local social services, Age UK or community mental health services. They do not need supplementation, they just require support for their nutritional needs, therefore, if nutritional support is needed, always make sure to utilise a route that is most appropriate for the current clinical condition of the patient 12. What is a fortified • Adding food to diet to increase energy and protein condiet? tent • It involves - eating smaller and more frequent meals - choosing snacks and fluids high in energy and protein eg high protein content yoghurt, crisps and cakes - adding calories/protein to food eg adding creams into 4 / 15 soups, eating extra butter • Powdered supplements can be taken, which are available off prescription eg Build-Up, Complan 13. What is supplementation? • Oral nutritional supplements (ONS) • They are usually required in addition to normal diet when food alone doesn't meet nutritional needs • If the oral route is available, safe and likely to meet the patients needs then it should be used compared to more invasive methods like nasogastric feeding and parenteral nutrition • You would usually take 1-3 cartons/bottles a day • There are a range of styles eg milk, juice, yoghurt, sweet/savoury • There are a range of formats eg liquids, powders (to mix into milkshakes), pudding style • There are a range of types eg high protein, high fibre, low volume, nutritionally complete or specific supplement, disease-specific • ONS is classified as a borderline substance, which means it can only be prescribed on an NHS prescription for standard ACBS indications, which include disease-related malnutrition, short bowel syndrome, intractable malabsorption, pre-operative preparation of malnourished patients, inflammatory bowel disease, total gastrectomy, dysphagia, bowel fistulae • Appendix 2/ the borderline substances section in the BNF contains a list of ONS with specific indications next to each one • An example of ONS is Nutricia Fortisip 14. What are enteral • A tube that is used to instill nutrition/fluids into the GI feeding tubes? tract, which may enter the nose, mouth, or abdomen • The type of tube used is determined by the length of time the patient will need enteral feedings/integrity of the GI tract • They are closed feeding systems which means they are in sterile pre-filled containers to reduce risks of infection entering the feed 5 / 15 • They are used for patients that are unable to eat and drink but they have a functioning gut (normal gastric emptying, normal motility etc) • They are invasive methods of nutrition support and are associated with greater risks compared to fortified diets and supplementation, so they should only be used if essential 15. What is naso-gastric feeding? • A nasogastric tube is a thin, yellow, narrow, soft tube. One end of the tube has two ports at the top: one is for food and the other could be for medication. The other end of the tube is where the food comes out of. • The tube enters the nose, travels down the oesophagus and ends in the stomach • It is used for short-term feeding for patients that are unable to eat and drink but they have a functioning gut. The inability to eat can be due to impaired swallowing due to stroke, where if they attempt to swallow, there would be potential for choking or aspiration, or due to unconsciousness. The patient is nil-by-mouth so has to be fed via a nasogastric tube • It can also be used to supplement oral intake when ONS are not sufficient or cannot be tolerated. This can be the case in patients with cystic fibrosis, anorexia nervosa, or with a facial injury, who need more to meet nutritional need 16. What are potential issues with a nasogastric feeding tube? • The tube itself may be uncomfortable initially, so requires time to get used to • There can be complications eg - incorrect tube placement, where the tube doesn't finish in the stomach but in the lungs for example - GI complications eg diarrhoea, constipation, aspiration - blockage of the tube, which can be due to food or medications - interactions of food with medicines or different medicines with each other (therefore rinse the tube out with water before anything new is added) 17. • A feeding tube in the jejunum of small intestine 6 / 15 What is jejunostomy feeding? 18. What is PEG feeding? • Percutaneous endoscopic gastrostomy (PEG) • A tube enters directly through the abdominal wall into the stomach • A minor surgical procedure takes place to be able to insert the tube in (therefore it is definitely for longer term use) • It is used for patients that are unable to eat and drink but they have a functioning gut, similar to NG feeding, but it is used for longer-term feeding eg when the patient is unable to swallow and is unlikely to regain the ability anytime soon 19. What are poten- • A problem when the tube is inserted into the body via tial issues with a surgery PEG feeding? • Blockage of the tube, even though PEG tubes are slightly wider in diameter • Tube site infections 20. What are enteral • Polymeric feeds (standard feed) feed solutions for • Pre-digested feeds (elemental/ semi-elemental) enteral tubes? • Disease-specific feeds • Immune-modulating feeds 21. What is parenter- • Nutritional feeding through the vein, directly into the al nutrition? central circulation via the superior vena cava • The feed is a white, fatty solution, contained in a bag • It goes through an IV central line from the neck area and it goes down near the heart • It bypasses the bodies natural defences therefore it must be sterile, hence it is manufactured in an aseptic unit (in a hospital or a manufacturing place) • It must be chemically and physically stable • It must meet the patients nutritional requirements • It is used only if the gut is not functioning properly or if it is inaccessible • Some patients can still eat while using the parenteral nutrition, however "total" parenteral nutrition is where the patient consumes no other food 7 / 15 • It is no more effective than other routes • It is expensive • It can increase the risk of serious complications compared to NG or PEG, eg infections and metabolic disturbances, as the feed enters directly into the central circulation which isn't a normal physiological way to receive nutrition. Therefore it is always used as the last option if there is no other route 22. What does the • Amino acids parenteral nutri- • Lipids tion bag contain? • Glucose • Vitamin/ minerals (water soluble and fat soluble) • Electrolytes, mainly sodium, potassium, magnesium, phosphate and calcium • This all creates a large volume of fluid which goes into the circulation • One bag can contain up to 2.5L, and the volume of fluids needs to be maintained. The daily requirements of maintenance fluids for an adult include - 30-35 ml/kg of water - 1mmol/ kg of sodium - 1mmol/ kg of potassium - 50-100g of glucose 23. What is Home Parenteral Nutrition? (HPN)? • Long-term parenteral nutrition • Approximately 1000 adults in the UK are on HPN • They can administer it themselves, or a nurse will see them everyday to administer it for them • The PN solution is contained in a bag/rucksack • The most common indication for HPN is short bowel syndrome, where there is a minimal length of bowel which is insufficient to absorb all of the nutrients that the person requires 24. Which healthcare professionals are involved in drug adminis- • The dietician needs to ensure that the patient is receiving the full volume of feed prescribed • The pharmacist makes sure the drugs are administered safety and at effective doses 8 / 15 tration via enteral • The doctor wants the drug and nutrition to work and feeding tubes? doesn't want to have to replace the tube • The nurse has to administer the medicine and feed without harming the patient or themselves • The patient needs their feed and their medication, and they may need to be independent in the future to give themselves the feed and medication on their own 25. What problems can occur with drugs and nutrients via NG and PEG tubes? • Chemical or physical interactions between the drug and a specific nutrient involved in drug metabolism • Practical administration issues eg having to crush medication can make things more difficult • Loss of drug effect due to impaired absorption, increased drug clearance or the blocking of pharmacological action 26. What chemical Interactions between the drug and components of the diet interactions can • Ciprofloxacin (antibiotic) absorption is reduced by 50% occur? by binding to ions in enteral feed • Phenytoin (anti-epileptic) and warfarin (anti-coagulant) bind to proteins in enteral feed, reducing drug levels • Digoxin (anti-arrhythmic) levels are reduced by high fibre levels (such as those in a fibre-rich enteral feed) • Antacids containing aluminium or magnesium can bind to dietary phosphate, reducing phosphate absorption 27. What physical in- • Between drug and feed component or feed formulation teractions can • Physical change in consistency of feed occur? • Can result in tube blockage or even blockage of GIT eg sucralfate and enteral feed, concentrated potassium liquids and enteral feed • Some drugs directly interact with the enteral tube itself eg carbamazepine drug molecules can adsorb onto the tube itself, so less of the drug is absorbed and available to the patient 28. What are the choices of formulation going in an enteral tube? • Solution • Syrup • Suspension- particles of a suspension can block the tube • Soluble tablet • Effervescent tablet 9 / 15 • Dispersible tablet • Standard tablets and capsules can be used as a last resort. They can be crushed or opened (however this needs to be checked against licensing) • Alternatives, disregarding the feed tube, include intravenous, intramuscular and subcutaneous injections or patches, if these are available. However if the patient has a long list of medications, it is unsuitable to have them all as injections, as this is too many fluids to inject into a patient and it can also be painful 29. How should medicines be administered via tubes? • Adequate flushing - flush excess feed out of the tube before putting medication in • Use liquids if possible • Don't mix drugs together • Do not crush enteric coated or sustained release tablets • Be aware of potential harm from inhaling crushed tablet powder • Be aware of the change in licensing status of certain medicines eg some capsules are not licensed to be opened 30. What is obesity? • Excessive accumulation of body fat • BMI (body mass index) over 30 • It is the century's biggest Public Health challenge 31. How much • Until Ideal Body Weight (IBW) is reached weight should be • Until BMI reaches <25 lost? • 5-10% of the total body weight can be lost • Until you reach the weight to fit into a piece of clothing/ to look like your favourite celebrity It should be realistic, achievable and maintainable 32. What are benefits • Mortality of a 10% weight - 20-25% reduction in total mortality reduction? - 30-40% reduction in diabetes-related deaths - 40-50% reduction in obesity-related cancer deaths • Blood pressure 10 / 15 - 10mmHg reduction (in diastolic and systolic BPs) • Diabetes - >50% reduction in risk of Type 2 diabetes - 30-50% reduction in fasting blood glucose • Lipids - 10% reduction in total cholesterol - 15% reduction in LDL - 30% reduction in triglycerides 33. How is weight loss achieved? Energy stored = energy intake - energy expenditure So to achieve weight loss (less energy stored), we need to reduce intake and/or increase expenditure Expenditure needs to be more than intake 34. What happens physiologically during weight loss? • Normally, carbohydrates are stored in the liver and muscles as glycogen • However when the body is starved, the glycogen storage is reduced, due to less nutrition, calorie intake, fat intake and carbohydrate intake • This causes an initial rapid reduction in weight, because there is a loss of glycogen (around 0.5kg lost) and a loss of water (around 1.5kg lost). This is what happens during "quick fix" diets, so mainly water is lost • If little to no carbohydrate intake continues, the body utilises fat and lean tissue to produce energy in order to survive • Once the body has been in a starvation state for around 10 days, the body tries to conserve lean tissue, so will break down fat to produce energy, and there will be an increase in the BMR (basal metabolic rate). At this point, weight loss is more sustainable • It is important to understand the basic principles of weight loss to determine which strategies should be most effective • Provide information to patients on health risks of obesity, 35. What are the NICE guidelines so they are adequately informed (rather than to scare to support pathem) • Set realistic weight loss targets, so this can be achieved 11 / 15 tients with obesi- and results can be seen, to avoid disappointment ty? • Focus on losing weight and then maintaining the weight loss, to lead to better health outcomes • Set realistic targets for increasing physical activity, and gradual progression in the increase in exercise • Recommend support groups • Encourage support of family 36. What are weight • Dietary strategies loss strategies? • Behavioural interventions • Physical activity • Pharmacological strategies/ medications • Surgery • Prevention and support strategies by society, rather than individual changes • Usually a combination of strategies are implemented, as there is no single intervention that is effective alone for either prevention or management of obesity 37. What are dietary • Energy intake should be less than expenditure strategies? • NICE recommends diets with 600 kcal/day deficit or reduced kcals by lowering fat content, plus support and follow-up • Low calorie diets (800-1600kcals/day) should only be carefully recommended, as they are less likely to be nutritionally complete, so patients may miss out on essential components • Very low-calorie diets (<800kcals/day) should not be recommended at all to manage obesity. They can be harmful and are not suitable for long-term • There needs to be a balanced diet with an adequate intake of all key nutrients, vitamins and minerals • Avoid "empty" calories eg full sugar drinks, where there are calories but no nutritional intake • Avoid consumption of energy dense foods eg donuts, which contain a lot of energy but are unlikely to make you full • Avoid reduced portion sizes • Aim for 0.5-1kg weight loss per week, as this is more 12 / 15 sustainable for long term • Look for life-long healthy eating patterns, rather than "quick-fix diets" or excluding certain foods altogether. Just keep a balance 38. How much of each nutrient should we aim to have for healthy weight management? • Calories- maintain an energy deficit of 500kcal • Total fat- less than 30% total energy intake • Saturated fat- 8-10% total energy intake • Protein- 15% total energy intake • Carbohydrate- over 55% total energy intake • Fibre- 20-30g per day • Water- 2L per day, increase in heat/exercise 39. What are evidence for dietary weight loss strategies? • NEJM (New England Journal Medicine) 2009 - 20% vs. 40% fat; 15% vs. 25% protein; 35% vs. 65% carbohydrates - Average 6kg weight loss (7%) after 6/12 - 2 years weight loss was comparable regardless of diet composition (high calorie, low calorie etc) • NIH 1998 - Low calorie diets: reduce total body weight by ~8% over 3-12/12, reduce abdominal fat but don't improve cardiac fitness - Low fat diets: only result in weight loss if overall reduction in energy intake • JAMA 2003 - Low carb diets: weight loss associated with reduced energy intake and not reduced carb intake • JAMA 1993 - Very low-calorie diets: average weight loss ~1.5-2.5kg/week but difficult to maintain • JAMA 1998 Very low-fat diets: achieve weight loss and reduction in cardiac events (limited evidence) • US study 2005: Characteristics of the diet of people that had maintained weight loss for 5 years - Majority ate low amounts of fat (about 24% of the total daily energy intake) - High amounts of carbohydrate 13 / 15 - A low overall energy intake (5460-6300 kJ/d) - Most eat breakfast daily - Self-monitor weight - Physically active - Monitor food portion size - Avoid the use of food to regulate mood • There is no evidence that one diet is more effective long term than another. 40. What diets should be recommended by pharmacists? • Do not recommend anything eg weight loss clubs, weight loss plans in magazines, diet products, celebrity endorsements or cooking books etc, without knowing it's safety and efficacy beforehand • The weight loss strategies and diets should be evidence based 41. What are be• Encourage patient to be more aware of eating habits and havioural strate- physical activity gies? • Self-monitoring, where patients keep a diary of food and activity • Changing eating habits - eating regular meals, and less snacks - chewing food more - not eating whilst watching TV, to encourage more "conscious" eating, which tends to slow down the eating - drinking more water, as triggers for thirst can get confused with triggers for food • Identify social and emotional triggers for eating. Once identified, change ways of thinking - stress management, as stress can cause someone to over-eat - assertiveness training, as it can be harder to say no to some foods with certain friends or family members - active and passive over-eating, as some people may not realise that they are over-eating 42. How can we • Ensure that the patient is aware of the importance of make behaviour- weight loss and weight maintenance • The patient can make written plans of what they want to 14 / 15 al changes that are lifelong? achieve • Access to social support and reinforcement by friends, family, weight loss groups and healthcare professionals • Accurate and honest recording of behaviour • Reassurance about "slips", make sure that they know it is normal and it doesn't mean that they have failed or that they should give up • Not about "quick fixes", as weight loss takes time so should be sustainable • Support life changes • Encourage variety and trying new foods • Developing cooking skills 43. What are physical activity strategies? • 30 minutes of moderately intense aerobic exercise 3-5x week • This helps to lower the risk of heart disease, and improves mood and sense of wellbeing • Encourage patients to adopt regular activities that they can enjoy and sustain long term • Start new activities at low intensity, and then increase gradually • Increase daily activity e.g. less TV watching, walk rather than use the bus, use the stairs not the lift 44. What are preven- • All sectors of society should support and reinforce tion and support healthy choices strategies? • The policies released by the government should promote healthy choices • Transport should be made more accessible and affordable • Educational organisations should promote activity and physical education (PE) • Leisure industry should be made more accessible and affordable • Food industry should promote healthier eating through advertising, and increase availability of healthier foods 15 / 15