Medical teachers usually refrain from teaching dietetics to medical students. As a result, doctors seldom prescribe full dietetic instructions. For example, instructions are commonly given to a patient to ‘avoid sour and spiced foods’ without specifying the forbidden items. Where facilities are available, dietetic prescriptions are prepared by a dietician. Unfortunately, dietetics facilities are not available everywhere, and hence the need for medical doctors to be able to prescribe a diet. Patients prefer to get advices from the doctor treating his or her sickness. Because doctors are not trained to give adequate dietary advice, the public turn to unqualified, unregulated bodies. Too much attention is being paid by people with eating ‘correct food’; this has killed the pleasure of eating. It focuses on the nutritional management of individual patients or groups of patients with established disease and aims to treat (and prevent) suffering from malnutrition.
This article will be highlighted the importance of nutrition management in sick adults and the easy way of screening them.
What is malnutrition?
The term malnutrition indicates a bad nutritional status. Nutritional status is the physiological state of an individual, which results from the relationship between nutrient intake and requirements, and the body’s ability to digest, absorb and use these nutrients. Malnutrition arises from deficiencies or excesses of specific nutrients, or from un-diversified diets (wrong kinds or proportions of foods). A distinction must be made between malnutrition and under nutrition.
What is under nutrition?
It is the outcome of insufficient food. It is caused primarily by an inadequate intake of dietary or food energy. It is defined as a dietary energy intake below the minimum requirement level to maintain the balance between actual energy intake and acceptable levels of energy expenditure. Co-existence of micronutrient deficiencies is also included.
Malnutrition in the hospitalised patient
More common among following categories: Patients admitted to medical wards, Preoperative patient, Postoperative patient, Cancer patient and Chronically ill.
Starvation and subsequent malnutrition may occur as complicating factor during the course of the patient’s illness. Death will occur from Protein Energy Malnutrition within 60-70 days of total starvation and functional metabolic deficits occur after 10-15 days of semi-starvation in previously healthy adults and shorter periods in those already compromised by disease. Consequences of starvation are weight loss, alterations in organ function, malaise, lethargy and changes in cognitive function.
Why is under nutrition important in management of sick?
Under nutrition has both physical and phycosocial effects which will directly or indirectly affect the prognosis of the disease.
Physical effects of under nutrition are impaired immune responses (predisposes to infection), reduce muscle strength and fatigue (inactivity, inability to work effectively, poor self care, abnormal muscle function), reduce respiratory muscle strength which will give poor cough pressure, predisposing to and delaying recovery from chest infection, inactivity, especially in bed-bound patient, predisposes to pressure sores and thromboembolism, Impaired thermoregulation, hypothermia, especially in elderly, impaired wound healing, failure of fistulae to close, un-united fractures, increased risk of wound infection resulting prolonged recovery from illness, increased length of hospital stay, delayed return to work, fetal and infant programming which predisposes to common chronic diseases: cardivascular, stroke, diabetes in adult life and Growth failure give rise stunting, delayed sexual development, reduce muscle mass and strength.
Psychosocial effects of under nutrition are Impaired psychosocial functions like Apathy, Depression, Self-neglect, Hypochondriasis, Loss of libido, Deterioration of social interactions, Affect personality, Mother-to-child bonding.
All these factors contribute to severity, duration, hospital stay and complications of the disease.
How do we assess Nutritional Status of sick adults?
Nutritional status can be assessed through body (anthropometric) measurements, weight and height, mid upper arm circumference (MUAC) in adults and body weight changes; clinical examination and biochemical testing, used to diagnose deficiencies of micronutrients (e.g. iodine, vitamin A and iron). Body Mass Index (BMI) will be calculated with weight and height of adults (BMI=Weight (kg)/Height2 (cm).
Below table provide the information on interpreting indicators and cut off points of BMI for adults.
LEVEL OF SEVERITY
Severe energy deficiency
≤ 16 or oedema
Moderate energy deficiency
Between 16 and 17
Marginal energy deficiency
Between 17 and 18.4
Malnutrition Universal screening tool (MUST) can be used to screen patients on admission. Weight and height can be taken on admission and the MUST can be applied to categorize the patients while taking the history and performing clinical examination. The chart below provides the scoring system. We can use one of the scoring system. If the weight and height measurement is feasible BMI score can be taken, If weight and height has not been taken on admission weight loss score can be adopted and in acute cases acute disease effect score can be adopted.
Overall risk of malnutrition and management guidelines
Use of parental or enteral nutritional support
• Maximum period of 7 days of a severely limited nutrient intake
• Weight loss of 10-15% recalled pre-illness weight
Guidence for Nutrition support group in modification of diet
• Interview the patient to determine his nutritional needs, dietary habits and food preference.
• Prescribe the diet in relation to dietary goals
• Total Carbohydrate – 55% - 75% of the calories
• Protein – 10-15% of the calories
• Total Fat – 15-30%
– Saturated fats < 10% of calories
– Poly unsaturated FA 6-10%
– n-6 PUFA 5-8%
– N-3 PUFA 1-2%
– Trans fatty acid <1%
– Monounsaturated FAs by difference
• Vegetables & fruits >=400g / day
• Cholesterol < 300mg / day
• Salt < 5g / day
• Non- starch polysaccharides 25g/day
• Free sugar <10% of calories
• Total dietary fibre from food
• Maintain the normal BMI of 18.5 – 24.9 kg/m2 and optimum BMI will be 21-23 kg/m2
-Dr. Renuka Jayatissa
-Dr. Renuka Jayatissa