Undernutrition

Tory Davis, PA-C

Malnutrition

 Undernutrition and overnutrition  Undernutrition can result from inadequate ingestion of nutrients, malabsorption, impaired metabolism, loss of nutrients due to diarrhea, or increased nutritional requirements (as in cancer or infection).

Stages of Undernutrition

 Each takes time to develop  First, nutrient levels in blood and tissues change  Second, intracellular changes in biochemical functions and structure  Finally, signs and symptoms

Risk Factors

 Ages and stages  Social circumstances: poverty  Medical conditions

Infancy and Childhood

 High demands for: – Vit E – Energy  – Essential nutrients  Nutrients req’d for nl body fxn that we can’t produce – must be obtained by diet Vegan mother breastfeeding  B12 deficiency

Adolescence

 Anorexia  Rapid growth

Pregnancy

 Fe deficiency anemia  Folate deficiency anemia  Pica – seen more in pregnancy – want to eat things that aren’t normally considered food – sometimes to replace nutrional deficit

Old Age

      Sarcopenia (progressive loss of lean body mass) begins at 40!

 physical activity  food intake – Anorexia  cytokine levels  androgen levels  Basic metabolic rate

Disorders/Procedures

 DM – can’t absorb  GI Tract disorders – Malabsorptions, IBD,Bowel resection – Impaired absorption of fats. Fat-sol vitamins, B12, Ca, Fe  Liver d/o – Impair metabolism of vit A, B12, protein

Disorders/Procedures

 Renal disorders – Deficiencies of protein, vit D, Fe  Increased metabolic demands – Infection, trauma, fevers, burns

Diets

 Vegetarian – B12 in vegans – Fe defic in ovo-lacto – Protein  Fad diets – Protein, vit, minerals – Ask Liberace

Diet

 Meds/drugs/supplements – – Alter appetite Alter absorption and metabolism  Etoh/Drugs – – Neglect of nutritional needs Etoh  deficiencies of Mg, Zinc, thiamine  Thus the “banana bag (mg, zinc thiamine + others).” Why? – see note below

Diagnosis of Undernutrition

 Hx: dietary intake, weight change, above risk factors  SHx: money for food? Able to prepare meals? Think elders!

 PE: BMI, look for signs of deficiencies OR conditions that could predispose to undernutition.

– Like what? Jaundice, spoon nails, wasted, pale (sign of anemia), hair loss or thinning, etc  MNA- Mini Nutritional Assessment

Testing- Labs

 Serum albumin as indirect measure – May indicate protein deficiency  Other testing – Vitamin/mineral levels as specific tests

PEM

 Protein Energy Malnutrition  Energy deficit secondary to chronic deficiency of all macronutrients  Graded mild to severe, based on percentage of expected wt  Primary- inadequate intake  Secondary from drug or d/o that interferes with nutrient use

PEM

 Developing countries: – Children who can ’t consume enough protein and calories  Lack of access  Developed countries: – – – Institutionalized elderly Abuse (child or elder) Pts with decreased appetite or impaired digestion/absorption/metabolism

Vitamins

 Organic compound required as nutrient in tiny amounts but can’t be synthesized by the organism and must be obtained via diet.

 See posted

vitamin chart

for sources, functions, effects of deficiencies

Vitamin Deficiencies in developed countries

 Poverty  Food faddism  Drugs (ie drug/vit interactions)  Alcoholism  Parenteral nutrition (prolonged or with inadequate supplementation)

S/S Nutritional Deficiency: General

 Wasting  Cachexia  Energy deficiency

Skin

 Rash – many vits (usually def), zinc, fatty acids  Rash in sun-exposed areas – Niacin (pellagra)  Easy bruising – Vit C or K

Hair/nails

 Thinning or loss of hair – Protein  Premature whitening of hair – Selenium  Spooning of nails – Iron

Eyes

 Impaired night vision and  Corneal keratomalacia – Vit A

Mouth

 Cheilosis (angular cheilitis) and glossitis – Riboflavin, niacin, pyridoxine, iron  Bleeding gums – Vitamin C, riboflavin

Extremities

 Edema – Protein def  Why?

Neuro

 Stocking/glove paresthesias and numbness – Thiamin  Tetany – Ca, Mg  Cognitive and sensory deficits – Thiamin, niacin, B12

MSSK

 Wasting – Protein  Bony deformities – Vit D, Ca  Bone tenderness – Vit D  Joint pain/swelling – Vit C

GI

 Diarrhea – Protein, niacin, folic acid, B12  Diarrhea with dysgeusia – Zinc  Dysphagia/odynophagia (Plummer Vinson syndrome) – Iron

Endo

 Thyromegaly – Iodine