Nutrition for Nurses
From the Editors’ Desk
Nutrition for Nurse. Medicine 2023;51(7).
(1). Benjamin Allen et al. Malnutrition and undernutrition: causes, consequences, assessment and management. Medicine 2023;51(7):P461-468.
The term ‘malnutrition’ is used to describe a deficiency, excess or imbalance of a wide range of nutrients, resulting in measurable adverse effects on body composition, function and clinical outcome. Malnutrition can refer to individuals who are either over- or undernourished, although it is usually used synonymously with undernutrition. Although it is well known that malnutrition is common in the developing world, it is not widely appreciated that it occurs frequently in UK health settings as a consequence of either psychosocial circumstances or the effects of illness or injury. Furthermore, because malnutrition has direct effects on clinical outcomes and is associated with significant healthcare expenditure, better recognition and treatment would improve patient outcomes and reduce costs. It is therefore the responsibility of all doctors and wider healthcare professionals to recognize the fundamental importance of proper nutritional care.
(2). Anne Holdoway. Oral nutrition support. Medicine 2023;51(7):P469-473.
Oral nutritional interventions to treat malnutrition in adults have been shown to improve mortality, morbidity, weight, anthropometry, dietary intake and quality of life. The National Institute for Health and Care Excellence recommends that malnutrition should be managed using oral nutrition support in individuals who can safely swallow and have a functioning gastrointestinal tract. Interventions comprise dietetic advice, dietary counselling, food fortification, texture-modified diets, altered meal patterns, assistance with feeding and the use of oral nutritional supplements when intake from food and drink alone is insufficient to meet requirements. Dietitians are skilled in undertaking detailed assessments and using anticipatory skills to determine an individual’s likelihood and ability to modify diet to increase intake and select the optimal nutrition support products. With millions affected by malnutrition there is a need for all healthcare professionals to take on some responsibility in identifying and managing malnutrition so that suitable interventions can be deployed in a timely manner. This chapter covers the management of malnutrition via the oral route, including: (1) differentiating between disease-related malnutrition (DRM) and non-DRM, (2) managing nutritional issues and addressing symptoms interfering with eating and drinking, (3) dietary advice to optimize nutrient intake, and (4) the use of oral nutritional supplements
(3). Nicola Burch. Artificial nutrition support. Medicine 2023;51(7):P474-479.
Malnutrition remains common in the UK despite medical advances, with 40% of adult inpatients being at risk of malnutrition on admission to hospital and many weighing less on discharge than on admission. It is widely acknowledged that malnutrition leads to poorer clinical outcomes, longer length of stay, increased complications and increased morbidity and mortality compared with a well-nourished state. This emphasizes the importance of screening for malnutrition and implementing a comprehensive nutritional care plan to help mitigate the risk and manage the patient’s nutritional status effectively. While most patients’ nutritional needs can be met with dietary modifications and oral nutritional supplements, a proportion of individuals require artificial nutrition support via enteral tube feeding (through the gastrointestinal tract) or parenteral route (intravenous feeding) due to the underlying nature of their disease process. This chapter aims to provide an overview of the various types of artificial nutrition support and outline the specific considerations that should be addressed when developing an artificial nutrition treatment strategy. It provides an overview of the approach to decision-making and highlights the multi-professional nature of such decisions, emphasizing the value of having a comprehensive and experienced nutrition support team to help guide and support decision-making.
(4). Buraq Abdulaema et al. Intestinal failure. Medicine 2023;51(7):P480-484.
Intestinal failure (IF) describes a reduction in gut function, often resulting from previous surgery, leading to malabsorption and malnutrition. Untreated, this can lead to dehydration, weight loss, electrolyte imbalance and death. Early recognition with referral to experienced multidisciplinary IF teams is crucial to achieve good outcomes. IF management includes the control of sepsis, prevention of complications, optimization of nutrition, definition of the underlying anatomy and planning of reconstructive surgery or use of medications to support intestinal function
(5). Charlotte S. Rutter et al. Intestinal transplantation. Medicine 2023;51:7:P485-489.
The UK has played a pivotal role in developing intestinal transplantation in adult and paediatric recipients. UK adult centres are among the most active worldwide, and improving 5-year survival outcomes are comparable with other solid organ transplant groups. Patients with complications of intestinal failure or other indications for multivisceral transplant are referred and undergo detailed assessment. Transplant centres have developed close working relationships with specialized intestinal failure centres to encourage timely referral. The National Adult Small Intestinal Transplant forum provides a national multidisciplinary review of patients considered for transplant. The indications and management of complications after intestinal transplant are discussed.
(6). Kirstine Farrer et al. Nutritional support in palliative care. Medicine, 2023;51(7):P490-492.
Making decisions to nutritional support in palliative care setting can be challenging. A multidisciplinary team approach is vital to deliver patient-centred care. The patient or their advocate should be involved when making decisions to instigate nutritional support, be it oral, enteral, via a tube or via the parenteral route. Oral nutrition plans (with oral nutritional supplements) are the mainstay of management and should be continued unless oral feeding becomes difficult, at which time enteral tube feeding can be considered. The last resort of support includes parenteral nutritional support if the gastrointestinal tract is inaccessible or not functioning.
(7). Pete Turner et al. Medical management of eating disorders. Medicine 2023;51(7):P493-497.
An increasing number of adults are being admitted to acute medical units for the management of eating disorders such as anorexia nervosa. In most cases nutrition support is the mainstay of treatment and must be introduced at an appropriate rate to avoid both refeeding and underfeeding syndromes. As most hospitalized patients have a high risk of refeeding problems, the optimum approach is to start low but build up rapidly to meet the full requirements for weight gain by days 4-7. To do this, a generous provision of electrolytes, such as potassium, magnesium and phosphate, and vitamins (especially thiamine) is crucial; however, caution must be taken not to overload patients with fluid and sodium in doing so. Practitioners must also be aware of the implications of infection, liver dysfunction and hypoglycaemia. Severely malnourished patients may not exhibit many of the usual features of infection so it is especially important to recognize the deadly triad of low body mass index, hypothermia and hypoglycaemia so that antimicrobial therapy can be rapidly administered.
(8). Alison Culkin et al. Refeeding syndrome. Medicine 2023;51(7):P498-502.
Refeeding syndrome is a group of biochemical shifts resulting in clinical symptoms that can occur in malnourished or starved individuals when reintroducing nutrition. The lack of an agreed definition makes the incidence difficult to determine. Risk factors proposed by NICE in 2006 lack specificity and sensitivity but act as a framework to identify individuals potentially at risk. During starvation, there is a reduction in insulin secretion and an increase in glucagon to promote glycogenesis. The introduction of carbohydrate results in insulin secretion, stimulating the sodium-potassium pump that drives electrolytes into cells. Severely low electrolyte concentrations or thiamine deficiency can affect respiratory, cardiac and neuromuscular function. NICE guidelines have been criticized for being overcautious and underfeeding individuals. Recent guidelines recommend starting energy provision at 10-20 kcal/kg, although higher energy intakes are appropriate in some specialized units. Generous amounts of electrolytes and thiamine should be provided from the onset of feeding, although there is a lack of evidence to recommend specific doses. Careful attention to fluid provision is required to reduce the risk of fluid overload and pulmonary oedema. Treatment of individuals at risk should be provided by health care professionals with training in nutrition support.
(9). Suzi Batchelor et al. The management of micronutrient imbalance: a practical guide. Medicine 2023;51(7):P503-508.
Micronutrients are required in varying quantities to maintain essential functions within the body. Many of these are obtained through dietary sources, but access to a diet balanced in micronutrients varies worldwide; micronutrient deficiencies are the cause of reversible global health problems including iron deficiency anaemia and blindness in children. Lifestyle preferences including alcohol use and vegetarianism can predispose to micronutrient imbalance, with a range of acute and chronic diseases also putting patients at risk. Symptoms associated with micronutrient imbalance vary and multiple deficiencies can coexist because of shared sites of absorption between many micronutrients. In some individuals multivitamin ingestion proves sufficient to correct abnormalities, but specific micronutrient replacement is often required. Recognized biomarkers are often used to assess the response to replacement, with active inflammation a common factor for rendering these values less helpful. Some micronutrients in therapeutic doses can cause supratherapeutic concentrations, which can be toxic and lead to signs and symptoms that are important to recognize in clinical practice.
(10). Obesity: medical management. Medicine 2023;51(7):P509-514.
Obesity is a chronic relapsing disease that is reaching pandemic levels. It is associated with excess morbidity and mortality by being directly associated with a number of mechanical and metabolic complications such as sleep apnoea, type 2 diabetes mellitus and coronary artery disease. The management of obesity with lifestyle intervention appears to be successful in the short term; however, the maintenance of reduced body weight is challenging because of complex physiological responses to energy restriction. Therefore, a shift towards the medical management of obesity has encouraged the development and testing of new drugs. This chapter summarizes the current medical management strategies that can be used to support the treatment of obesity, as well as describing emerging pharmacological agents that demonstrate weight loss that approaches what can be achieved with bariatric surgery.
(11). Michael A. Glaysher et al. Obesity: surgical management. Medicine 2023;51(7):P515-518.
Obesity is a chronic health condition associated with progressive metabolic co-morbidities and ill-health. Currently available pharmacological, behavioural and dietary strategies provide mild to modest levels of weight reduction that are often not sustained. Bariatric and metabolic surgery remains the most efficacious and cost-effective means of treating individuals with obesity by producing profound and sustained weight loss, as well improvements in metabolic co-morbidities, mobility and quality of life. Several surgical procedures now exist in routine practice and there is evolving interest in minimally invasive therapeutic options, including bariatric endoscopy. Herein, we provide a review of the commonly performed endoscopic and bariatric surgical procedures, and their indications, outcomes, mechanisms of action and potential complications.
(12). Dominic Crocombe et al. The ethics of clinically assisted nutrition and hydration in adults. Medicine 2023;51(7):P519-522.
The provision of clinically assisted nutrition and hydration (CANH) often presents clinicians with an ethical challenge, which, in the context of changing health and social demographics, is set to increase. The subject is incredibly emotive for patients, relatives, carers and staff as food and water represent the most basic requirements for life. Modern society is an amalgam of different religious, ethnic and cultural backgrounds, and beliefs. Attitudes to end-of-life care and the sanctity of life vary widely between different groups. This is also present within multiprofessional healthcare teams and guidance is available to support discussions and decision-making for ethically complex care. The legal position regarding the provision of CANH varies between countries and states; however, all clinicians have a moral and professional responsibility to act within the principles of medical ethics and respect patients’ wishes, accepting that patients do not have the right to obtain every treatment they wish or request if the treatment is not medically indicated. Some of the most challenging situations arise in patients who lack capacity. The first question should be ‘what are we trying to achieve’? If in doubt, a trial of clinically assisted nutrition and hydration with clearly agreed objectives may be appropriate.