Malnutrition

Malnutrition is a nutrient deficiency state, whether of protein, energy or micronutrients (vitamins and minerals)¹. This causes measurable harm to body composition, function or clinical outcome.
(Note, overnutrition and resulting obesity are sometimes included within the general definition of 'malnutrition' but see separate guidance)

Protein-energy malnutrition (PEM)

2 forms:

1. Kwashiorkor Fair-to-normal energy intake, but inadequate protein. Associated with oedema and hepatomegaly. Word comes from the Ghanian language, Ga, and implies "the disease that the young child develops when displaced from his mother's breast by another child or pregnancy".
2. Marasmus Inadequate energy and protein intake. Associated with severe wasting.

Micronutrient deficiencies

Deficiencies in iron, iodine, Vitamin A and zinc remain major public health problems in developing countries².

Malnutrition is both a cause and consequence of ill health: we tend to visualise malnutrition as solely affecting starving children in the developing world but it is common at home, particularly in the elderly and hospitalised populations and massively increases a patient's vulnerability to disease.

• Globally, malnutrition is the most important risk factor for illness and death. It disproportionably affects children and pregnant women. It is the direct cause of about 300,000 deaths p.a. and indirectly responsible for about half of all deaths in young children (malnutrition increases the risk of death from diarrhoea, lower respiratory tract infection, malaria and measles)².
• WHO estimates that by 2015, prevalence of malnutrition world-wide will be 17.6% - with the vast majority living in developing countries in southern Asia and sub-Saharan Africa. An additional 29% will have stunted growth due to poor nutrition.
• In the UK, malnutrition affects 10-55% ill adults in hospital and the community and amongst hospitalised children 16% were found to be severely stunted, 14% wasted and 20% at risk of malnutrition if nutritionally stressed³.
• Amongst the elderly: malnutrition affects 1% healthy individuals in the community, 4-5% patient receiving home help living at home, 20% in hospital patients, and 37% in institutionalized individuals (Swiss study)⁴.

Risk Factors

In children:

• Under fives - most vulnerable are premature babies and infants at time of weaning.
• Children with co-existing chronic illnesses or developmental delay.
• Neglect by care-givers
• Poverty and its complex relationships with:
  • Political and economic situation.
  • Education.
  • Sanitation.
  • Season and climatic conditions.
  • Food production and security.
  • Cultural and religious traditions.
  • Prevalence of infectious diseases.
  • Availability and effectiveness of nutrition programmes and health services

In elderly:

• Living alone.
• Instititutionalisation.
• People with severe learning difficulties or mental health problems (depression, dementia).
• Diseases that affect appetite, eating/swallowing or GI function (gastric surgery, malabsorption, stroke, neurological disorders such as motor neurone disease).
• Catabolic states.

Presentation In adults

Adults tend to lose weight - often insidiously. Oedema may mask weight loss.

Presentation in children^{2 6}

PEM:

• Poor weight gain.
• Slowed linear growth.
  

  WHO criteria for identifying children with severe malnutrition: Bipedal oedema. Visible severe wasting. Weight for height > -3 standard deviations from median of international reference population.

Three clinical syndromes (note, mixed pictures may occur):

• Marasmus - obvious loss of weight with gross reduction in muscle mass especially from limb girdles. Subcutaneous fat virtually absent. Thin, atrophic skin lies in folds. Pinched face has appearance of old man or monkey. Alopecia and brittle hair. Sometimes appearance of lanugo hair.
• Kwashiorkor - usually occurs in children aged 1-2 years with changing hair colour to red, grey or blonde. Moon facies, swollen abdomen (pot belly), hepatomegaly and pitting oedema. Dry, dark skin which splits where stretched over pressure areas to reveal pale areas.
• Nutritional dwarfism - patient is small for age. Face shape may be affected by size of teeth versus face.

Elderly failure-to-thrive ⁷(weight loss >5% of baseline, decreased appetite, poor nutrition, inactivity) - consider in addition to malnutrition:

• Impaired physical function (for example, infection, malignancy, renal or heart failure).
• Depression.
• Dementia.

• Dehydration.
• Severe infection.
• Hypoglycaemia.
• Anaemia.

• Anthropometric assessment - height, weight (height and weight for age and weight for height are sensitive markers in childhood), BMI (used mainly in adults), mid upper arm diameter (overdiagnoses among younger children, undiagnoses among older children), skin folds.
  Note, standardised reference tables need to be appropriate for use with a particular ethnic group and may not be accurate for elderly populations.
• For the investigation of malnourished children in developing countries, WHO recommends:
  • Blood glucose.
  • FBC and film.
  • Urine MC&S.
  • Stool OC&P.
  • serum albumin.
  • HIV test.
  • U&Es.
  Note, tuberculin skin testing is less reliable in the malnourished child.
  Additional tests to assess nutritional status may include:
  • Iron studies, folate, B12.
  • Pre-albumin, transferrin, retinol-binding protein (better short-term indicators of protein status than albumin alone).
  • Thyroid function tests.
  • Coeliac serology.
  • Calcium, Phosphate, Zinc.
  • Vitamin levels - if deficiency suspected.
• Most accurate evidence of malnutrition in an elderly patient is hypocholesterolaemia and hypoalbuminaemia⁷.

General measures for elderly population in UK:

• General nutritional advice.
• Use of supplements - more effective than nutritional advice alone⁸.
• Inability to shop/prepare meals - refer to social services, meals on wheels, community dietician, local day centres.
• Factors such as increasing number of people present at meals⁹, improving the palatability of meals and finding optimal time of day and location of meals may also improve intake.
• Difficulty with feeding utensils - refer to occupational therapy to consider aids/equipment.
• Nausea - consider anti-emetics.
• Oral pathology - treat if present.
• Dysphagia - investigate and refer to speech and language therapy. If not amenable to treatment, consider pureed food or thickened fluids.

Acute management of severely malnourished ⁶

• Clinical assessment - check for co-existing dehydration, infection, anaemia, hypoglycaemia
• Correct shock and dehydration and restore electrolyte balance. Reverse malnutrition without overloading cardiac, renal, GI, or hepatic function.
• Often need to treat coexisting infection (high prevalence - such that WHO recommends use of empirical antibiotics for first 7 days).
• Many need vitamin replacement and treatment of hypoglycaemia with IV glucose and/or oral sucrose.
• Cases showing hypothermia require warming.
• Rehabilitation phase of treatment: starts as child's appetite returns, usually a week after treatment is started. Many essential nutrients are still deficient. Children should receive at least 130kcal/kg/day. Frequent feeds, with gradual increases in energy and protein intake to avoid cardiac failure.
• Progress is monitored by daily weighing with weight gain target of 10-15g/kg/day.
• Identify causes and involve family/community in prevention of relapse.

• Slower wound healing.
• Increased risk of infection.
• Decreased muscle strength.
• Poor cognition.
• Increased dependency.
• Increased mortality.

Chronic malnutrition (particularly where associated with intrauterine growth retardation or early onset) leads to persistent growth retardation and cognitive deficit¹⁰.
Prognosis for PEM worse with co-existent HIV infection.

In adults (NICE guidelines)¹

Screening for malnutrition and for those at risk of developing it should take place:

• All hospital inpatients on admission and repeated on a weekly basis during admission.
• All outpatient attendees at first clinic appointment.
• On entering a care home.
• At initial registration with a GP and opportunistically at, for example, influenza vaccination.
• Where clinical concern exists.

Screening should assess BMI, percentage unintentional weight loss and consider time scale of reduced nutritional intake and likelihood of this continuing in the future. Tools such as MUST (Malnutrition Universal Screening Tool)¹¹ exist to aid this assessment.

• Use appropriate fortified standard foods as first-line treatment of malnourished patients prior to use of supplements.
• Always use in conjunction with appropriate dietary advice.
• Do not prescribe on a long-term basis without regular monitoring and reassessment.
• Nutritional needs and food intake determine the number of supplements needed - usually not more than 500-600 Kcal daily (approximately 2 cartons of sip feed) unless under care of a dietician.
• Supplements should be given between meals and not with or instead of a meal.
• Try different flavours and types of feeds to avoid boredom.
• Only prescribable on the NHS for ACBS (Advisory Committee on Borderline Substances) approved conditions (short bowel syndrome, malabsorption syndromes, pre-operative preparation of malnourished patients, inflammatory bowel disease, total gastrectomy,dysphagia, bowel fistulae, disease-related malnutrition).

Consider carefully consent issues and whether or not the provision/withdrawal of nutritional support is appropriate - GMC guidance is available¹⁴.

In childhood

• Good prenatal nutrition - importance of pre-conceptual and antenatal care
• Promotion of breastfeeding.
• Health promotion/education- regular age-appropriate nutritional advice and counselling during childhood.
• Specific programmes addressing micronutrient supplementation/fortification (eg Vitamin D, iodine) according to population needs.
• Improvement of hygiene and sanitation to reduce infectious disease and parasitic load.
• Global political and economic commitment to achieving UN millennium development goals (specifically: the reduction of levels of extreme poverty and hunger to half 1990 levels by 2015)