• Its main disadvantages is that the recent food intake is not included,
and calculations of the percentage weight loss, and of the BMI, have
caused problems in some units
Nutritional Risk Screening (NRS-2002)
Answer
• Is BMI < 20.5? YES NO
• Has the patient lost YES NO
weight during the last
3 months?
• Is the dietary intake
reduced in the last YES NO
week
• Is the patient severely YES NO
ill? (e.g. ICU)
If ‘No” to all questions, re-screened at weekly intervals
If “Yes” to any questions, the final screening is performed
Kondrup et al, Clin Nutr 2003
Nutritional Risk Screening (NRS-2002) Final Screening
• (Risk of Malnutrition)
Absent Score 0 Normal nutritional status
• Muscle-Strength
• Mobility
Muscle Strength
Muscle strength
Is a good predictor of outcome:
• In chronic situations:
– Aging
– Organ failure (renal failure, COPD, heart failure)
• In acute situations:
– Surgery or trauma
– Second hit (superimposed infection when already
subject to inflammatory activity)
Handgrip strength and outcome
Lower handgrip strength at hospital admission is
associated with:
• Longer hospitalization time
• No difference in men and women
• No difference in surgical and medical patients
Handgrip strength as a predictor of
nutritional status in hospital
• HGS and PG-SGA correlated
significantly
• HGS can independently predict nutrition
status and change nutrition status defined
by PG-SGA score and category, although
future longer term research is required to
confirm the use of HSG as an early
detection tool for malnutrition risk
Measurement Immune Function
• Lymphopenia and DHR are not good
parameters for the nutritional assessment
FM FFM/lean mass
FM BCM ECM
FM BCM ECM
Models of Body Composition
Molecular Model : Normal Body Composition
• 12 kg storage fat (triglycerides)
• Subcutaneous
• Intramuscular Fat 15 kg
• Intraabdominal 3kg essential fat
• Bone marrow lipids Fat
• CNS lipids Protein 12,8 kg
Age 25 Age 70
70
50
40
Water 61% Water 61%
30
20
Impaired wound
healing
Wound dehiscence
Negative energy balance
• Adaptation
Negative energy balance
Adaptation Inflammation
Healing problem
Muscle wasting
Energy reserves are clinically
important
Frequently, common
sense is not common
Case Scenario 1
A 69 years old woman
Cholangiocarcinoma stage IV
• Carcinomatosis peritonei, lung
metastasis
• Plan: Palliative chemotherapy
• Loss of appetite, early satiety,
fatigue, dysgeusia, constipation
• Bed-bound for 50% of daytime
• Able to eat less than half of usual
dieet for months
• Usual BW 60kg (-6 months ago)
• Actual BW 45.8 kg
• Ht 154 cm (BMI 7)
Methods to assess body composition
• Anthropometry
• Under-water weighing
• DEXA
• Bioelectrical impedance analysis (BIA)
• ?
Case Scenario 1
Micronutrient deficiency
protein-energy malnutrition (PEM)
Classification of PEM Body mass index (kg/m2)
Normal ≥ 18.5
Mild 17.0-18.4
Moderate 16.0-16.9
Severe <16.0
Cut-off point for reduced muscle mass
Examples of recommended thresholds for reduced muscle mass
Males Females
Appendicular skeletal muscle index (ASMI, < 7.26 < 5.25
kg/m2)
Appendicular lean mass adjusted for BMI = < 0.725 < 0.591
ALM/BMI
Cut-off point for reduced muscle mass
• Examples of recommended threshold for reduced muscle mass
Males Females
Appendicular skeletal muscle index (ASMI, < 7.26 < 5.25
kg/m2)
Standar meal:
• 2000 kcal, protein 60 g, CHO 290 g, fat 70 g
How much you can eat?
Standar meal
• 2000 kcal, protein 60 g, CHO 290 g, fat 70 g
Refractory Cachexia
Normal weight loss > 5% or BMI < 20
and weight loss > 2% or Variable degree of cachexia
sarcopenia and weight loss > Cancer disease both
weight loss > 5% 2% procatabolic and not
Anorexia and Often reduced food responsive to anticancer
metabolic intake/systemic inflammation treatment
change Low performance score < 3
month expected survival
1900 2000
Undernutrition Undernutrition
&
overweight
Obesity
n= 450 undernourished
PG-SGA
29%
Overweight/obese
BMI ≥ 25 kg/m2
63%
Prevalence and clinical implications of
sacrcopenic oesity in patients with solid tumours
of the respiratory and gastrointestinal tract: a
population-based study
CT Scans
Sarcopenicoesity (15%)
• “independent predictor
of survival irrespective
of age, sex, and
functional status”
Bioelectrical Impedance Analysis
Body
Composition
Phase Angle
Refractory Cachexia
Normal weight loss > 5% or BMI < 20
and weight loss > 2% or Variable degree of cachexia
sarcopenia and weight loss > Cancer disease both
weight loss > 5% 2% procatabolic and not
Anorexia and Often reduced food responsive to anticancer
metabolic intake/systemic inflammation treatment
change Low performance score < 3
month expected survival
2.5 g/day of
EPA + DHA
ORIGINAL ARTICLE
Oral nuttitional supplements containing n-3
polyunsaturated fatty acids affects quality of life and
functional status in lung cancer patients during
multimodality treatment: an RCT
Normal protein anabolic respone to
hyperaminoacidemia in insulin-
resistant patients with lung cancer
cachexia
Spesific nutrient and tumor growth
• Do nutrient stimulate the growth of cancer
cells?
• Does nutritional support in cancer patients
accelerate tumor growth in a clinically
relevant manner?
• Do malnourished cancer patients live longer
than wellnourished cancer patients?
Brain tumor initiating cell adapt to
restricted nutrition through
preferential glucose uptake
Caloric restriction and differential
stress respone in oncology
Major problem = malnutrition
Pharmalogic topics
Appetite stimulation
• Corticosteroid
• Progestins
• Cannabinoids
• Ghrelin
• Cyproheptadine
• Brached-chain amino acids
• Herbal medicine,bitter
Corticosteroid
Progestins: Effect on WEIGHT in
patients with cancer cachexia (11 RCT)
Progrestins
Cochrane metaanalysis 2005
31 RCT (n=4123 MA) vs PLAC: appetite +, weight +
Metaanalysis 2008
30 RCT (n=4430) MA vs PLAC: appetite +, weight +,
survival Ø, QoL Ø
Stimulation of appetite
Increase in body weight, but no increase in LBM
Improve QoL
Dronabinol (5 mg THC)
Vs placebo:
Taste +, appetite +
Energy intake +, protein intake +
Ghrelin and Analogues
Ghrelin and Analogues
Anamorelin: Romana trials
Exercise as anabolic signal!
Anti-inlamatory agents
• Corticostreroids
• Progestagens
• Cannabinoid
• Non-steroidal anti-inflammatory drugs (NSAID)
• N-3 fatty acids
• Anti-cytokines
• Melatonin
• Antioxidants
NSAID
The Refeeding Syndrome – prevention
• Identify patients at risk
• Correct and monitor phosphorous / K, Na, Cl,
Mg
• Nutritional support: “start slow (<50% of
calculated energy) and advance slow”
• Supplement vitamins (B1, B6, B12)
NSAID in cancer cachexia
• Systematic review: 13 students (6 controlled
studies)
– Studies are small
– Suboptimal design
– Many studies without comparator
– In 11/13: stabilization or improvement of WT or
LBM
• NSAIDS may improve weight in cancer patients
• Evidence is too frail to recommend
N-3 fatty acids
• Cochrane systematic review
• On 5 RCT: insufficient data
Circulatory:
• Severe acute cardiac insufficiency
• Shock of any origin
Conclusion I
• The goal of EN is prevention/treatment of
malnutrition to improve outcome
• Main indications of EN are:
– Inadequate oral intake for >7 days
– Present / imminent malnutrition
• Main contraindications of EN are:
– Severe dysfunction of the GI tract
– Metabolic / circulatory instability
Complications of EN
• Gastrointestinal
• Aspiration
• Metabolic
• Tube related
Complications of EN
Problem Frequency
Compliance 10-40%
Tube misplacement / Up to 50%
occlusion
Nausea / vomiting 10-15%
Diarrhoea 25-50%
Infections Rare
Metabolic complications ?
Aspiration ?
Reasons for diarrhea during EN
• Bolus application
• High delivery rate
• High osmolality
• Bacterial contamination of the formula diet
• Formula diet is too cold
• Gastrointestinal infections
• malabsorption
Work up of diarrhoea during EN
• Switch to continuous application
• Decrease the delivery rate (temporarily)
• Avoid bacterial contamination ( change drip
line daily, deliver formulae within 6-10 hours)
• Review prescriptions (prokinetics, antibiotics,
antacids, atropine etc)
• Exclude GI infections (stool culture,
Clostridium Difficile)
• In malabsorption change to low molecular
diets
• If Diarrhoea persists change to a fibre-free EN
formula
Reasons for impaired gastric emptying
during EN
• Pre-existing diseases:
– Diabetes mellitus
– Vagotomy
– Systemic scleroderma
– Myopathies
• Acute disease related:
– Pain and stress
– Pancreatitis
– Spinal cord injury
– Extensive trauma, abdominal surgery, burn injuries
• Medication :
– Opioids
– anticholinergics
Work up of nausea/vomiting during EN
micronutrient
deficiency
Risk factors for refeeding syndrome
• The patient has one or more of the following O :
– BMI <16
– Unintended weight loss >15% for the pat 3-6 months
– Minimal or no food intake for 10 days
– Low levels of phosphate, potassium and magnesium
before starting nutritional support
• Or the patient has one or more of the following
– BMI <18.5
– Unintended weight loss >10% for the pat 3-6 months
– Minimal or no food intake for >5 days
– Histroy of alcohol or drug abuse
The Refeeding Syndrome - findings
• Hypophosphataemia
• Hypokalaemia
• Hypomagnesaemia
• Thiamine (and other vitamin) deficiency
• Fluid retention
Neuromuscular dysfunction
Hypoventilation
Metabolic acidosis
Cardiac arrhytmia
Wernicke’s encephalopathy
Monitoring of Enteral Nutrition
Feed administration Daily
Fluid Balance Daily
Laboratory tests
•Na, K, Glucose Initially daily
•P, Ca, Urea, Creatinin, Initially twice / week
ALT, Blood count
Nutritional status Weekly / every 2nd week
•Weight, albumin
•Bioimpedance analysis
Functional status weekly
•Hand grip strength
HOSPITAL FOOD AND ORAL
NUTRITIONAL SUPPLEMENTS (ONS)
Council of Europe Committee of
Ministers
Nutritionally well
Nutritionally Vulnerable
Nutritionally vulnerable
High risk of malnutrition due to:
• An acute or chronic illness affecting their appetite
and their nutritional intake
• Cognitive decline or limited ability to
communicate with the medical staff
• Increased or altered nutritional requirements due
to the underlying medical condition (e.g. surgery,
burns, trauma, diabetes, chronic kidney disease)
• Disturbed swallowing or chewing ability, poor
dentition or dysphagic patients
Characteristics of hospital diets
• A minimum of 300 kcal per main meal and 500 kcal for an
energy dense meal and at least 18 g protein with each meal
• A minimum of two courses at the midday and evening
meals
• A vegetarian choice on each eating occasion
• A choice of portion sizes for all meals
• A variety of snacks, providing a minimum of 150 kcal, at
least twice a day. Fruits should always be a choice
• Standard recipes should be used
• An “out of hours” meal must be available for all patients
who missed their meal. The “out of hours meal should
provide at least 300 kcal and 18 g of protein”
Provision of nutrients for the
hospitalised adults
Common thypes of hospital diets
• The standard diet • Diets with increased meal
• Diets with altered nutritent frequency
content – e.g. for patients with
– Low residue, clear liquid gastrectomy
diets, full liquid ciets, • Elimination diets
soft diet – lactose-free, gluten-free,
• Diets with modified texture diets free from specific
allergens, etc
– Blenderised, pureed diets
• Protein- and/or energy- • Diets for metabolic
enriched dietsenergy disorders
restricted diets – e.g. diet for phenylketonuria
diets for specific medical
conditions
Food intake in 1707 hospitalised
patients: a prospective hospital survey
Protein intake
as % of
proteins
needs
Monitoring of nutritional intake
Monitoring of nutritional intake
• Supervision of tray collection
38% of food from the kitchen was returned as waste
Ensuring adequate nutritional intake
• Protected Mealtimes Policy (HCA)
“3 mealtimes free from avoidable and
unnecessary interruptions”
Acceptance of hospital diets and
nutritional status among inpatients
with cancer
Acceptance of hospital diets and
nutritional status among inpatients with
cancer
Malnutrition in Hospital
Meals consumption in the hospital and
probability of death
From food to parenteral nutrition
• All admissions: hospital
food. Ward nurses and
medical teams screen
patients
• Some patients require
oral nutritional
supplements: may
require assessment by
dietitians
• Enteral feeds: dietitians
• Nutrition support team
• Parenteral Nutrition
Food fortification
• Fortification of food with
– Energy CHO Fat and
CHO
– Protein Fat
• Fat
• Butter/buttermilk
• Milk
• Cheese
• Sugar
• Supplements of CHO/
protein/fat
Food Fortification
Pros Cons
• Cheap • May change tase. Sensory
• Does not alter food volume properties
• Easy in preparation • Not easy to provide disease
• Extra energy specific nutrients
• Needs action from
patient/caregiver
Monitoring and improving intake
Fortification
Advantages Disadvantages
• Simpole • Cumbersome
• Inexpensive • Sensoreic limitation!
• Single macronutriens
can be added
• Nutritional intake is
enhanced
Oral nutritional supplements and food
fortification
If the patient is at risk of malnutrition or
malnurished
and
Work/economic