Definitions

• Cachexia: weight loss, wasting of muscle, loss of appetite, and general debility that can occur during a chronic disease
• Catabolism: “destructive metabolism” – refers to the biochemical reactions that break down molecules in metabolism – molecules may be broken down for energy or to prepare them for disposal
• Cheilosis: painful inflammation and cracking that develops at the edges of the mouth
• Cytokines: soluble substances (glycoproteins) that act as local messengers or regional hormones (secreted by one cell that cause it or other cells to proliferate, differentiate, migrate, or become activated) – hundreds have been discovered and they all have their own unique functions in the homeostatic and genetic controls over cellular function
• Sarcopenia: loss of muscle tissue as a natural part of the aging process

Anatomy/Physiology

Describe the process of carrying out a nutrition focused physical examination. What characteristics are indicative of malnutrition?

Prior to conducting the nutrition focused physical examination, you want to review the patients’ medical record to obtain already-documented information. Upon entering the patients room, wash your hands thoroughly, and put on gloves if you wish/if appropriate. Before conducting the exam, introduce yourself to the patient/family, let them know what you will be doing and why you are doing it, and ask the patient for permission to examine them. If the patient is able to, conduct an interview assessment first – a nutrition assessment to help determine possible causes of malnutrition/symptoms if it is not malnutrition. The next step is to conduct the physical assessment – “head-to-toe assessment” – beginning at the head and working your way down. Throughout the exam you are looking for signs of muscle and fat loss, any nutrient deficiencies or toxicities, as well as any edema in order to determine if the patient is malnourished. Before ending the exam, make sure to ask the patient if they have any questions or concerns. Afterwards, let them know what the next steps will be (e.g., consult with physician), establish a goal with the patient (e.g. maintain current muscle and fat mass), indicate how this goal will be achieved (e.g. continue monitoring for signs of malnutrition, physician will help with symptoms), and state the expected outcomes of achieving this goal (e.g. patient will feel normal again – more energy, healthier, etc.). If the patient is unable to participate due to a critical illness or confusion then it is a little more difficult to conduct the exam, and the goal is to examine the areas that are available.

Loss of subcutaneous body fat (e.g. orbital, triceps, fat overlying the ribs), muscle loss (e.g. wasting of the temples, clavicles, shoulders, interosseous muscles, scapula, thigh, and calf), fluid accumulation (generalized or localized edema – extremities, vulvar/scrotal edema, or ascites), and reduced grip strength are all characteristics indicative of malnutrition

Characteristics indicative of mild-moderate malnutrition include:

• Subcutaneous fat loss
  • Orbital region – surrounding the eye – slightly dark circles, somewhat hollow look
  • Upper arm region – triceps/biceps – some depth pinch, but not ample
  • Thoracic and lumbar region – ribs, lower back, midaxillary line – ribs apparent, depressions between them less pronounced, iliac crest somewhat prominent
• Muscle loss
  • Temple region – temporalis muscle – slight depression
  • Clavicle bone region – pectoralis major, deltoid, trapezius muscles – visible in male, some protrusion in female
  • Clavicle and acromion bone region – deltoid muscle – acromion process may slightly protrude
• Edema – need to rule out other causes of edema first!
  • Mild to moderate pitting, slight swelling of the extremity, indentation subsides quickly (0-30 sec)

Characteristics indicative of severe malnutrition include:

• Subcutaneous fat loss
  • Orbital region – surrounding the eye – hollow look, depressions, dark circles, loose skin
  • Upper arm region – triceps/biceps – very little space between folds, fingers touch
  • Thoracic and lumbar region – ribs, lower back, midaxillary line – depression between the ribs very apparent, iliac crest very prominent
• Muscle loss
  • Temple region – temporalis muscle – hollowing, scooping, depression
  • Clavicle bone region – pectoralis major, deltoid, trapezius muscles – protruding, prominent bone
  • Clavicle and acromion bone region – deltoid muscle – shoulder to arm joint looks square, bones prominent, acromion protrusion very prominent
• Edema – need to rule out other causes of edema first!
  • Deep to very deep pitting, depression lasts a short-moderate time (31-60 sec), extremity looks swollen

Pathophysiology

Describe the relationship between serum protein levels and nutritional status.

• Total protein (serum) levels are not specific to disease or highly sensitive; they can reflect poor protein intake, illness or infections, changes in hydration or metabolism, pregnancy or medications. There is no single test that is both sensitive and specific for protein-calorie malnutrition. Many non-nutritional factors affect serum protein concentrations in varying degrees
• Albumin – it is neither sensitive nor specific for acute protein malnutrition or the response to nutrition therapy – a non-sensitive measure of visceral protein status
• Globulin, e.g., transferrin – slightly more sensitive to dietary changes in protein than albumin – serves as an indicator of protein status because it is sensitive to acute changes in protein intake or requirements – a measure of visceral protein status
• Prealbumin (transthyretin) – more responsive to health status changes than albumin or transferrin – this is a more sensitive marker for protein and/or calorie deficiency and is more responsive to nutrition therapy – but this sensitivity means it is more likely to be a reflection of recent dietary intake than an accurate reflection of nutritional status – a measure of visceral protein status
• C-reactive protein indicator of inflammation or disease – not useful as a nutritional marker – can be helpful in establishing whether or not the acute phase response has altered serum protein levels
• Blood urea nitrogen(BUN)– a measure of somatic protein
• Creatinine – daily urine output of creatinine can be correlated with total muscle mass – it is a byproduct of muscle metabolism so low levels signal a decrease in muscle mass because creatinine in the blood is proportional to skeletal muscle – a measure of somatic protein

How does malnutrition contribute to edema?

Blood vessels become “leaky” in protein malnutrition, which allows plasma proteins to movie into the tissues. Since proteins attract water, the tissues swell, causing edema

What are the metabolic differences between malnutrition related to chronic diseases as compared to simple lack of food?

Chronic diseases can alter appetite, digestion, absorption, or nutrient metabolism, leading to malnutrition. Metabolic abnormalities caused by alterations in regulatory hormones, cytokines, and systemic inflammation can also occur, and these alterations can lead to loss of muscle tissue. Another concern is that people with chronic illnesses typically have increased energy needs due to increased energy expenditure, altered endogenous glucose production and lipolytic rates, and protein breakdown, but many also experience decreased appetite making it difficult to meet those elevated needs. These issues can be maintained and treated but cannot be cured without curing the chronic disease. Malnutrition related to simple lack of food can lead to a decreased metabolic rate, loss of digestive functions (decreased rate of peristalsis, pancreas reduces production of digestive enzymes), diarrhea, altered blood lipids, and low blood proteins.

Describe three ways in which advocacy and policy decisions can impact malnutrition in developing and developed countries. How are these similar? How are they different?

1. Improve household food security by adopting developmental strategies and economic policies that create conditions for growth, accelerate growth in the food and agriculture sectors and promote rural development that focuses on the poor, improve access to land and other natural resources, providing supplemental aid (e.g. SNAP), or increase employment opportunities
2. Protect consumers through improved food quality and safety by implementing strict food regulations and standards, as well as effective inspection systems, educate consumers about proper food safety, or monitor national incidence of food-borne diseases and contaminants
3. Prevent specific micronutrient deficiencies by fortifying foods, improving water quality, or educating consumers on how to eat a balanced, healthy diet

All of these require the government to implement effective legislations, policies, and regulations. It also requires the public to pay attention to any education, warning, or assistance that is being provided. Food security depends on the ability to produce or procure enough food to ensure an adequate diet. If people cannot access healthy food, they will become malnourished. Food security also ties into food quality and safety. In order to provide an environment in which everyone can achieve food security, the food available needs to be of good nutritious quality and be safe to consume (no harmful contaminants, bacteria, etc.). If a country does not have good food quality and safety, they need to focus their strategies and actions on that first before addressing food insecurity and deficiencies. Because with improved food quality and safety, and improved food security, there should be a decrease in micronutrient deficiencies.

What role is the most appropriate role for enteral or parenteral nutrition support with nutrition related to chronic disease?

• Enteral nutrition support is appropriate for individuals
  • with at least 2-3 feet of functional GI tract
  • who are malnourished or will become malnourished
  • who have inadequate oral intake to restore or maintain nutrition status
• Chronic diseases frequently requiring enteral nutrition
  • Due to impaired nutrient ingestion – neurological disorders, HIV/AIDS, oral or esophageal trauma, respiratory failure
  • Due to impaired nutrient ingestion, absorption, and metabolism – Crohn’s disease, short bowel syndrome with minimal resection, cancer
• Parenteral nutrition support is appropriate for individuals
  • who are malnourished or who will become malnourished
  • who have insufficient GI function to be able to restore or maintain nutrition status