11/14/24, 10\:55 AM Malnutrition

Malnutrition

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Malnutrition\: sudden or chronic decrease in nutritional intake a
Types\:
Acute malnutrition\: brief inadequate nutrition (e.g., due to illness) leading to muscle wasting and rapid weight loss.
Chronic malnutrition\: prolonged inadequate nutrition (over three months) often related to social, behavioural, economic,
and illness-related causes.
Incidence\: over 30% of hospitalised patients experience malnutrition.
Screening\: all hospitalised patients should be screened using tools like MUST, MST, and MNA.
Causes\:
Inadequate nutrient intake
Di
Increased nutritional demands (e.g., post-surgery)
Risk factors\: chronic illnesses, elderly, supported accommodation residents, prolonged alcohol consumption, extended
hospitalisation, dental/taste/smell problems, polypharmacy, social isolation, mental health issues, cognitive issues.
Clinical features\:
High infection susceptibility or prolonged infections
Slow or poor wound healing
Altered vital signs (bradycardia, hypotension, hypothermia)
Depleted subcutaneous fat and low skeletal muscle mass
In children\: wasting (low weight for height), stunting (low height for age), underweight (low weight for age)
History\:
Weight history\: current weight, recent changes, clothes
Meal history\: meal regularity, skipping meals
Protein intake\: high-quality protein consumption
Hydration\:
Clinical examination\:
Weight and BMI
Muscle mass and subcutaneous fat review
Consider grip strength, triceps skin fold thickness, mid-arm muscle circumference
Management\: treat malnutrition like any other medical condition, involving dietitians; address reversible causes (e.g.,
infection).
Oral nutrition\: high-energy-high-protein supplements, forti
Nasogastric feeding\: if oral intake insu
Long-term feeding\: gastrostomy or jejunostomy
Parenteral nutrition\: for intestinal failure or inaccessible digestive tracts
Refeeding syndrome\: rapid reintroduction of nutrition in chronically malnourished patients can cause hypokalaemia and
hypophosphataemia, leading to cardiac complications and seizures. Gradual reintroduction and electrolyte monitoring are
essential.
Complications\: impaired immunity, poor wound healing, growth restriction in children, unintentional weight/muscle loss,
multi-organ failure, death.
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A comprehensive topic overview

Introduction

Malnutrition refers to a sudden or chronic decrease in the intake of su
for growth, healing, and maintenance of life. Malnutrition can be acute or chronic\:
Acute malnutrition\: a brief period of inadequate nutrition that is most commonly in relation to an acute illness with a
high in
Chronic malnutrition\: inadequate nutrition that lasts longer than three months. Often secondary to social, behavioural,
and economic factors in addition to illness-related causes.
It is estimated that over 30% of patients admitted to hospital will experience a form of malnutrition.
1,2
All patients admitted to hospital should be screened for malnutrition including measurement of their weight, body mass
index (BMI) and appetite. Several standardised screening tools exist including the Malnutrition Universal Screening Tool
(MUST), the Malnutrition Screening Tool (MST) and Mini-Nutrition Assessment (MNA).
4

Aetiology

Normally, as metabolic demands increase due to illness, injury or stressors such as exercise, people are able to adapt
their nutritional intake to meet their body's requirements.
In settings of chronic disease and certain drugs, this can become extremely di
malnutrition.
There are three main reasons why someone might become malnourished\:
Inadequate amounts of nutrients (e.g. poor variety in diet)
Dicoeliac disease)
Increased nutritional demands (e.g. post-surgery for healing)

Risk factors

Those most at risk of malnutrition are patients with chronic illnesses, the elderly, those living in supported accommodation
and patients drinking excessive amounts of alcohol over a prolonged period.
Other risk factors for malnutrition include\:
Being hospitalised for extended periods of time
Problems with dentition, taste or smell
Polypharmacy
Social isolation and loneliness
Mental health issues including grief, anxiety and depression
Cognitive issues including confusion

Clinical features

A comprehensive nutrition-focused history and exam should occur to evaluate the cause and severity of the malnutrition
and determine an appropriate management plan.
Typical clinical features of malnutrition include\:
3
High susceptibility or long durations of infections
Slow or poor wound healing
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Altered vital signs including bradycardia, hypotension, and hypothermia
Depleted subcutaneous fat stores
Low skeletal muscle mass
In children, other indicators of undernutrition include\:
Wasting\: low weight for height
Stunting\: low height for age
Underweight\: low weight for age
Serum albumin
Hypoalbuminaemia occurs in conditions where there is an excessive amount of protein being lost (e.g. protein-
losing enteropathy, chronic renal disease) or where the production of albumin is impaired (e.g. liver disease due to
loss of synthetic function or malnutrition due to a paucity of protein). Hypoalbuminaemia can also develop in the
context of in
assess a patient's nutritional state as there are a wide variety of factors which in

History

Important areas to cover in the history include\:
Weight history\: including current weight, recent changes to weight and changes to
Meal history\: regularity of meals including skipping meals
Protein intake\: intake of high-quality protein
Hydration\: intake of

Clinical examination

Clinical examination of a patient with suspected malnutrition should include\:
Weight\: unexpected weight loss from someone’s normal weight is indicative of a period of malnutrition. This includes
people who are clinically overweight and obese.
Body mass index (BMI)\: a patient’s BMI indicates whether they might be malnourished. It is not however as accurate as
history and clinical examination, and should never be used in isolation.
Review of muscle mass stores
Review of subcutaneous fat stores
Consideration could also be given to measuring a patient’s grip strength, triceps skin fold thickness and mid-arm muscle
circumference.
5

Management

Malnutrition should be treated like any other medical condition with consideration of the patient's goals of care, prognosis,
and other social factors. Dietitians should be involved in leading the management of patients with malnutrition.
If a speci
soon as possible.
Method of feeding2
Oral nutrition should be used as long as it is possible, with the use of oral nutritional support such as high-energy-high-
protein supplements and forti
patient's nutritional status.
If a patient is unable to safely swallow or is unable to take su
considered. For long-term feeding, a gastrostomy (PEG or RIG) or jejunostomy should be considered.
Parenteral nutrition should be reserved for patients with intestinal failure or inaccessible digestive tracts.
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Refeeding syndrome7
Refeeding syndrome is a condition caused by a rapid re-introduction of normal nutrition in patients who are
chronically malnourished. In the context of chronic malnutrition, a patient's intracellular stores of key electrolytes
such as potassium and phosphate become depleted. As a result, if a patient is suddenly provided with normal levels
of nutrition, there is a sudden shift of these electrolytes from the extracellular to the intracellular compartment
driven by a large insulin response and other factors. This can ultimately lead to a sudden drop in extracellular
levels of key electrolytes resulting in hypokalaemia and hypophosphataemia. This can subsequently lead to
cardiac complications (e.g. arrhythmias) and seizures.
To prevent refeeding syndrome, nutrition is re-introduced more gradually under the guidance of a dietician and the
patient's electrolytes are monitored closely, allowing de

Complications

Complications of malnutrition include\:
Impaired immunity (increased risk of infections)
Poor wound healing
Growth restriction in children
Unintentional weight loss, speci
Multi-organ failure
Death

References

Shimizu Y. Malnutrition. WHO. 2022. Available from\: [LINK]
ASPEN | DeLINK]
Stewart R. Handbook of clinical nutrition and dietetics. Sixth edition. ed\: Australian Dietitian; 2020.
Validated Malnutrition Screening and Assessment Tools\: Comparison Guide. Health.qld.gov.au. 2022. Available from\: [LINK]
Hummell A, Cummings M. Role of the nutrition‐focused physical examination in identifying malnutrition and its
eLINK]
Bretscher C, Boesiger F, Kaegi-Braun N, Hersberger L, Lobo D, Evans D et al. Admission serum albumin concentrations and
response to nutritional therapy in hospitalised patients at malnutrition risk\: Secondary analysis of a randomised clinical trial.
eClinicalMedicine. 2022;45\:101301.
Nickson C. Refeeding Syndrome. Life in the Fast Lane. 2022. Available from\: [LINK]

Related notes

Acute Pancreatitis
Barrett’s Oesophagus
Coeliac Disease
Crohn's Disease
Hyperlipidaemia
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Contents

Introduction
Aetiology
Risk factors
Clinical features
Management
Complications
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