Advanced Nutrition and Dietetics in Nutrition Support -  - ebook

Advanced Nutrition and Dietetics in Nutrition Support ebook

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Written in conjunction with the British Dietetic Association, Advanced Nutrition and Dietetics in Nutrition Support provides a thorough and critical review of the fundamental literature in nutrition support. Extensively evidence-based and internationally relevant, it discusses undernutrition, nutritional screening, assessment and interventions, as well as key clinical conditions likely to require nutrition support, and the appropriate care of these. Clinically oriented and written specifically for nutritionists and dietitians, Advanced Nutrition and Dietetics in Nutrition Support is the ideal reference for all those managing malnutrition and undernutrition in patients.

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Table of Contents

Cover

Title Page

Preface

Foreword

Editor biographies

Contributors

Abbreviations

SECTION: 1 Background to undernutrition

Chapter 1.1: Definitions and prevalence of undernutrition

1.1.1 Undernutrition: definition and diagnostic criteria

1.1.2 Prevalence of undernutrition

References

Chapter 1.2: Physiological causes of undernutrition

1.2.1 Altered metabolism

1.2.2 Reduced oral intake

1.2.3 Reduced absorption

References

Chapter 1.3: Socioeconomic causes of undernutrition

1.3.1 Introduction

1.3.2 Socioeconomic differences in diet and nutrition

1.3.3 Food insecurity

1.3.4 Food security and socioeconomic factors

1.3.5 Psychology of undernutrition

1.3.6 Summary

References

Chapter 1.4: Institutional causes of undernutrition

1.4.1 Introduction

1.4.2 Identification and consequences of institutional undernutrition

1.4.3 Determinants of institutional undernutrition

1.4.4 Causes of undernutrition in long‐term care

References

Chapter 1.5: Consequences of undernutrition

1.5.1 Introduction and background

1.5.2 Physical consequences of undernutrition

1.5.3 Psychological consequences of undernutrition

1.5.4 Economic consequences of undernutrition

1.5.5 Summary

References

SECTION: 2 Identification of undernutrition

Chapter 2.1: Nutritional screening

2.1.1 Introduction

2.1.2 Purpose of screening

2.1.3 Screening methods

2.1.4 Process following screening

2.1.5 Implementing screening in healthcare settings

2.1.6 Conclusion

References

Chapter 2.2: Nutritional assessment

2.2.1 Background

2.2.2 Process of nutrition assessment

2.2.3 Summary

References

Chapter 2.3: Anthropometric assessment of undernutrition

2.3.1 Introduction

2.3.2 Weight

2.3.3 Height

2.3.4 Body mass index

2.3.5 Mid‐upper arm circumference

2.3.6 Triceps skinfold

2.3.7 Mid‐arm muscle circumference

2.3.8 Calf circumference

2.3.9 Bioelectrical impedance analysis

References

Chapter 2.4: Biochemical assessment in undernutrition

2.4.1 Introduction

2.4.2 Baseline biochemical tests

2.4.3 Biochemical interpretation and application

2.4.4 Summary

References

Chapter 2.5: Clinical assessment of undernutrition

2.5.1 Introduction

2.5.2 Functional assessment of nutritional status

2.5.3 Clinical status

2.5.4 Conclusion

References

Chapter 2.6: Dietary assessment in undernutrition

2.6.1 Introduction

2.6.2 Determining the ‘ideal’ dietary assessment tool

2.6.3 The utility of traditional dietary assessment methods

2.6.4 Retrospective methods of dietary assessment

2.6.5 Prospective methods of dietary assessment

2.6.6 Summary

References

Chapter 2.7: Advanced imaging techniques for assessment of undernutrition

2.7.1 Introduction

2.7.2 Advances in imaging techniques

2.7.3 Summary

References

SECTION: 3 Nutritional requirements in nutrition support

Chapter 3.1: Fluid requirements and assessment in nutrition support

3.1.1 Hydration status: physiopathology

3.1.2 Assessment of hydration status

3.1.3 Summary

References

Chapter 3.2: Energy requirements in nutrition support

3.2.1 Introduction

3.2.2 Measurement of energy expenditure

3.2.3 Estimation of total energy requirements

3.2.4 Summary

References

Chapter 3.3: Protein requirements in nutrition support

3.3.1 Metabolic requirement for protein

3.3.2 Assessment of protein requirements

3.3.3 Amino acid requirements

3.3.4 Protein requirements of older adults

3.3.5 Protein requirements in acute illness

References

Chapter 3.4: Water‐soluble vitamins in nutrition support

3.4.1 Introduction

3.4.2 Vitamin recommendations

3.4.3 Water‐soluble vitamins

3.4.4 Summary

References

Chapter 3.5: Fat‐soluble vitamins in nutrition support

3.5.1 Introduction

3.5.2 The normal diet

3.5.3 Effects of disease on absorption and metabolism of fat‐soluble vitamins

3.5.4 Undernutrition and acute illness

3.5.5 Vitamin A

3.5.6 Vitamin D

3.5.7 Vitamin E

3.5.8 Vitamin K

3.5.9 Summary

References

Chapter 3.6: Minerals in nutrition support

3.6.1 Introduction

3.6.2 Electrolytes

3.6.3 Trace elements

3.6.4 Other trace elements

3.6.5 Mineral requirements for enteral and parenteral nutrition

References

SECTION: 4 Nutritional interventions to prevent and treat undernutrition

Chapter 4.1: Population and community interventions to prevent and treat undernutrition

4.1.1 Introduction

4.1.2 Current policy on undernutrition

4.1.3 Community interventions to tackle undernutrition

4.1.4 Conclusions, challenges and the future

References

Chapter 4.2: Institutional interventions to prevent and treat undernutrition

4.2.1 Introduction

4.2.2 Creating a culture of nutrition support within institutions

4.2.3 Improving food services

4.2.4 Creating positive mealtime environments

4.2.5 System‐level nutrition processes: how to implement change into practice

4.2.6 Summary

References

Chapter 4.3: Oral nutrition support to prevent and treat undernutrition

4.3.1 Introduction

4.3.2 Outcomes appropriate for the assessment of effectiveness of oral nutrition support

4.3.3 Oral nutrition support options

4.3.4 Evidence for food‐based options

4.3.5 Oral nutrition supplements

4.3.6 Food‐based interventions combined with oral nutrition supplements

4.3.7 Supportive strategies aiming to improve oral nutrition intake

4.3.8 Summary

References

Chapter 4.4: Enteral nutrition to prevent and treat undernutrition

4.4.1 Introduction

4.4.2 Enteral nutrition formulas

4.4.3 Disease‐specific formula

4.4.4 Administering enteral nutrition

4.4.5 Outcomes of patients treated with enteral nutrition

References

Chapter 4.5: Parenteral nutrition to prevent and treat undernutrition

4.5.1 Indications for parenteral nutrition

4.5.2 Routes of parenteral nutrition

4.5.3 Formulation of parenteral nutrition

4.5.4 Monitoring

4.5.5 Complications of parenteral nutrition

4.5.6 Conclusion

References

SECTION: 5 Undernutrition and nutrition support in clinical specialties

Chapter 5.1: Nutrition support in paediatrics

5.1.1 Introduction

5.1.2 Definition of undernutrition in paediatrics

5.1.3 Prevalence of undernutrition in paediatrics

5.1.4 Common causes of undernutrition in paediatrics

5.1.5 Pathophysiology of undernutrition in paediatrics

5.1.6 Consequences of undernutrition in paediatrics

5.1.7 Identifying undernutrition in paediatrics

5.1.8 Frequency of monitoring, catch‐up growth and follow‐up in paediatrics

5.1.9 Nutrient requirements during undernutrition in paediatrics

5.1.10 Feeding advice as part of the management of undernutrition in paediatrics

5.1.11 Nutrition intervention for infants and children with faltering growth

References

Chapter 5.2: Nutrition support in anorexia nervosa

5.2.1 Introduction

5.2.2 Anorexia nervosa

5.2.3 Nutritional assessment in anorexia nervosa

5.2.4 Nutritional, psychological and pharmacological intervention in anorexia nervosa

References

Chapter 5.3: Nutrition support in older adults

5.3.1 Introduction

5.3.2 Prevalence of undernutrition

5.3.3 Causes of undernutrition in older adults

5.3.4 Consequences of undernutrition

5.3.5 Assessment and diagnosis of undernutrition in older adults

5.3.6 Nutritional interventions

References

Chapter 5.4: Nutrition support in neurological disorders

5.4.1 Introduction

5.4.2 Undernutrition: prevalence, causes and consequences

5.4.3 Screening and assessment of nutrition status in neurological disorders

5.4.4 Nutrition intervention

References

Chapter 5.5: Nutrition support in spinal cord injury

5.5.1 Introduction

5.5.2 Causes and mechanisms of undernutrition after spinal cord injury

5.5.3 Nutrition‐related complications in spinal cord injury

5.5.4 Assessment and diagnosis of undernutrition in spinal cord injury

5.5.5 Nutrition intervention

5.5.6 Summary

References

Chapter 5.6: Nutrition support in pulmonary and cardiac disease

5.6.1 Undernutrition in cardiopulmonary disease

5.6.2 Mechanisms for weight loss and muscle wasting

5.6.3 Consequences of undernutrition

5.6.4 Nutritional assessment

5.6.5 Nutrition management

5.6.6 Future directions and conclusions

References

Chapter 5.7: Nutrition support in diabetes

5.7.1 Introduction

5.7.2 Hyperglycaemia in hospitalised patients with diabetes

5.7.3 Undernutrition in diabetes

5.7.4 Oral nutrition support in diabetes

5.7.5 Enteral nutrition in diabetes

5.7.6 Parenteral nutrition in diabetes

5.7.7 Conclusion

References

Chapter 5.8: Nutrition support in pancreatitis

5.8.1 Acute pancreatitis

5.8.2 Chronic pancreatitis

5.8.3 Nutritional assessment in chronic pancreatitis

5.8.4 Nutritional requirements

5.8.5 Nutrition intervention in chronic pancreatitis

5.8.6 Monitoring

References

Chapter 5.9: Nutrition support in inflammatory bowel disease

5.9.1 Undernutrition in inflammatory bowel disease

5.9.2 Assessment and diagnosis of undernutrition

5.9.3 Dietary management

5.9.4 Long‐term impact

References

Chapter 5.10: Nutrition support in intestinal failure

5.10.1 Introduction

5.10.2 Nutrition interventions

5.10.3 Intestinal transplantation

5.10.4 Future interventions

References

Chapter 5.11: Nutrition support in liver disease

5.11.1 Liver disease

5.11.2 Causes and consequences of undernutrition in liver disease

5.11.3 Nutritional assessment of patients with liver disease

5.11.4 Nutrition support in liver disease

5.11.5 Specific aspects of nutritional management in liver disease

5.11.6 Lessons for practice

References

Chapter 5.12: Nutrition support in kidney disease

5.12.1 Introduction

5.12.2 Undernutrition in kidney disease

5.12.3 Aetiology of undernutrition in kidney disease

5.12.4 Consequences of undernutrition in kidney disease

5.12.5 Assessment of undernutrition in kidney disease

5.12.6 Nutritional management of undernutrition in kidney disease

5.12.7 Conclusions

References

Chapter 5.13: Nutrition support in critical care

5.13.1 Overview of undernutrition in critical illness

5.13.2 Mechanisms of undernutrition in critical illness

5.13.3 Metabolic and nutritional consequences of critical illness

5.13.4 Assessment and diagnosis of undernutrition in critical illness

5.13.5 Nutritional management and interventions in critical illness

5.13.6 Summary

References

Chapter 5.14: Nutrition support in burn injury

5.14.1 Incidence and severity of burn

5.14.2 Pathophysiology and impact of undernutrition

5.14.3 Nutrition assessment and monitoring

5.14.4 Route and timing of nutrition support

5.14.5 Energy and nutrient requirements

5.14.6 Immuno‐nutrition

5.14.7 Non‐nutritional management of hypermetabolism

5.14.8 Summary

References

Chapter 5.15: Nutrition support in orthopaedics

5.15.1 Introduction

5.15.2 Undernutrition in orthopaedic inpatient populations

5.15.3 Nutrition screening in orthopaedic settings

5.15.4 Nutrition assessment and nutritional diagnosis

5.15.5 Estimating requirements for orthopaedic conditions

5.15.6 Approaches to the management of undernutrition in orthopaedic patients

5.15.7 Monitoring and evaluation in orthopaedic patients

References

Chapter 5.16: Nutrition support in HIV infection

5.16.1 Background and prevalence of undernutrition in HIV

5.16.2 Causes of undernutrition in HIV

5.16.3 Consequences of undernutrition in HIV

5.16.4 Nutritional assessment and diagnosis of undernutrition in HIV

5.16.5 Clinical and nutritional management of undernutrition in HIV

5.16.6 Future research needs

5.16.7 Resources

References

Chapter 5.17: Nutrition support in oncology

5.17.1 Introduction

5.17.2 Background to undernutrition in cancer

5.17.3 Causes and mechanisms of undernutrition during cancer treatment

5.17.4 Consequences of undernutrition in cancer

5.17.5 Assessment and diagnosis of undernutrition in cancer

5.17.6 Interventions for nutrition support in cancer

5.17.7 Undernutrition and living with and beyond cancer

5.17.8 Palliative care

5.17.9 Summary

References

Chapter 5.18: Nutrition support in palliative care

5.18.1 Introduction

5.18.2 Undernutrition in palliative care

5.18.3 Nutrition support in palliative care

5.18.4 Palliative care and nutrition support decision making

5.18.5 Food and hydration at the end of life

5.18.6 Decision‐making tools and options for nutrition interventions

5.18.7 Early communication and application to nutrition practice

References

Index

End User License Agreement

List of Tables

Chapter 1.2

Table 1.2.1 Key hormones involved in appetite regulation with sites of release and modes of action

Table 1.2.2 Summary of the main causes of malabsorption by region of the gastrointestinal (GI) tract

Table 1.2.3 Drug‐induced malabsorption by mechanism of action

Chapter 2.3

Table 2.3.1 Estimated contribution of fluid to body weight in patients with alcoholic hepatitis and ascites [6] and with oedema [7]

Table 2.3.2 Adjustment of body weight following amputation or with an immoveable cast

Chapter 2.4

Table 2.4.1 Other biochemical parameters used in the assessment of a patient for nutrition support [1]

Table 2.4.2 Definition of systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis and septic shock [24]

Chapter 2.5

Table 2.5.1 Summary of common quality of life and functional measurement tools

Table 2.5.2 Summary of selected clinical scoring tools

Chapter 2.6

Table 2.6.1 Steps for consideration of the utility of dietary assessment methods for appraisal of undernourished patients

Table 2.6.2 Basic review of the likely capacity of undernourished individuals to complete traditional dietary assessment methods

Chapter 2.7

Table 2.7.1 Overview of available body composition techniques and relevance for clinical practice

Chapter 3.1

Table 3.1.1 Recommendations for adequate water intake expressed as volume in litres/day except Belgium (including fluid from food and beverages)

Table 3.1.2 Advantages and disadvantages of methods available for assessing hydration status

Chapter 3.2

Table 3.2.1 Substrate oxidation variables, VO

2

, CO

2

and energy expenditure during fat, protein and carbohydrate oxidation

Table 3.2.2 The percentage by which the FAO/WHO/UNU equations overestimate (+) or underestimate (−) BMR in different ethnic groups by sex, all ages 3–60 years

Table 3.2.3 Henry prediction equations for BMR based on weight, and weight and height

Table 3.2.4 Comparison of BMR prediction equations against the US Dietary Reference Intake (DRI) dataset

Table 3.2.5 Revised estimated average requirements (EAR) for infants aged 1–12 months

Table 3.2.6 Revised estimated average requirements (EAR) for children aged 1–18 years

Table 3.2.7 Stress factors for some clinical conditions

Table 3.2.8 Physical activity level (PAL) of hospitalised patients

Chapter 3.3

Table 3.3.1 Estimated requirements for essential amino acids in adults

Chapter 3.4

Table 3.4.1 UK and SACN recommendations in the healthy population [2]

Table 3.4.2 WHO recommendations for the healthy population

Table 3.4.3 ESPEN and European recommendations for the healthy population [4,5]

Table 3.4.4 US recommendations for dietary reference intakes [7]

Table 3.4.5 Comparison of recommendations for folate intake [2,4,5,7,9,12,13]

Table 3.4.6 Comparison of recommendations for vitamin C intake [2,4,5,7,23,24]

Table 3.4.7 Comparison of recommendations for thiamine intake [2,4,5,7]

Chapter 3.5

Table 3.5.1 SACN recommendations (reference nutrient intakes) for fat‐soluble vitamins in the healthy population [1]

Table 3.5.2 Population reference intakes for fat‐soluble vitamins published by the Scientific Committee for Food [2]

Table 3.5.3 Dietary reference intakes for fat‐soluble vitamins in males [6]

Table 3.5.4 Dietary reference intakes for fat‐soluble vitamins in females [6]

Table 3.5.5 WHO recommended nutrient intakes for fat‐soluble vitamins [8]

Table 3.5.6 Parenteral requirements for fat‐soluble vitamins in infants, children and adults [13,15]

Chapter 3.6

Table 3.6.1a Daily oral or enteral requirements for electrolytes in healthy adults

Table 3.6.1b Daily oral or enteral requirements for trace elements in healthy adults

Table 3.6.2 Recommended Adult Daily Parenteral Trace Element Requirements

Table 3.6.3 Trace element content of selected IV trace element solutions

Chapter 4.3

Table 4.3.1 Outcomes used in the assessment of oral nutrition interventions

Table 4.3.2 Oral nutrition support options available, practical considerations for their use and the influence of patient setting

Table 4.3.3 Summary of findings on nutritional, functional and healthcare outcomes for ONS from individual systematic reviews and meta‐analyses

Chapter 4.4

Table 4.4.1 Enteral nutrition formulations

Table 4.4.2 Summary of current recommendations for use of fibre in enteral nutrition

Table 4.4.3 Improvements in outcome with enteral nutrition in benign and malignant disease

Chapter 4.5

Table 4.5.1 Key studies raising concerns over use of parenteral nutrition (PN) lipids in hospitalised patients

Table 4.5.2 Monitoring of parenteral nutrition (PN)

Table 4.5.3 Monitoring of patients with suspected parenteral nutrition (PN)‐related bone disease

Chapter 5.1

Table 5.1.1 Factors and their implications unique to the nutritional management of paediatrics [1,7,8]

Table 5.1.2 Hormones and growth factors that affect nutritional status

Table 5.1.3 Theoretical energy and protein intake for 5, 10 and 20 g/kg/day catch‐up growth

Table 5.1.4 Comparison of energy and protein provided in standard infant formula (SIF) compared to protein energy‐enriched (PEE) infant formula

Chapter 5.2

Table 5.2.1 DSM classification of bulimia nervosa and anorexia nervosa

Table 5.2.2 Nutritional and clinical markers for risk assessment in AN patients

Chapter 5.3

Table 5.3.1 Summary of key micronutrient requirements in older adults

Chapter 5.4

Table 5.4.1 Mortality, length of hospital stay and hospitalisation costs in patients following stroke, according to risk of undernutrition as determined by the Malnutrition Universal Screening Tool (MUST)

Table 5.4.2 Summary of the International Dysphagia Diet Standardisation Initiative framework

Chapter 5.5

Table 5.5.1 Energy, protein, fluid and micronutrient needs for patients with SCI and pressure ulcer

Chapter 5.7

Table 5.7.1 Data from a meta‐analysis of diabetes‐specific formulas (DS‐EF) versus standard formulas on glycaemic outcomes. Data represent the favourable effect of DS‐EF over standard formulas, where they exist

Chapter 5.9

Table 5.9.1 Nutritional problems and considerations

Chapter 5.10

Table 5.10.1 Studies investigating the effect of oral nutrition supplements and enteral formula composition in short bowel intestinal failure

Chapter 5.11

Table 5.11.1 Use of late‐evening (nocturnal) feeding in cirrhosis

Table 5.11.2 Vegetable versus animal protein in cirrhosis and chronic encephalopathy

Table 5.11.3 Calcium and/or vitamin D for liver disease‐associated bone disease

Chapter 5.12

Table 5.12.1 Summary of the potential mechanisms contributing to undernutrition in chronic kidney disease

Table 5.12.2 Screening and assessment of undernutrition in kidney disease

Table 5.12.3 Protein intake recommendations across key guidelines and stages of chronic kidney disease

Table 5.12.4 General guidelines for fluid, potassium, phosphate and sodium recommendations on dialysis [35,37]

Table 5.12.5 Randomised controlled trials and controlled clinical trials targeting undernutrition via oral nutrition support in chronic kidney disease

Chapter 5.13

Table 5.13.1 Hormonal effects on protein metabolism

Table 5.13.2 The most influential RCTs in critical care nutrition

Chapter 5.14

Table 5.14.1 Summary of recommendations [2,7,8,18]

Chapter 5.15

Table 5.15.1 Key monitoring and outcome measures in orthopaedic inpatients [32]

Chapter 5.16

Table 5.16.1 Common AIDS‐defining conditions and their nutritional consequences

Table 5.16.2 Prevalence of undernutrition in HIV

Table 5.16.3 Anthropometry in HIV

Chapter 5.17

Table 5.17.1 Prevalence of undernutrition in different diagnostic groups from studies of nutrition screening or nutritional assessment in cancer [4,45]

Table 5.17.2 Symptoms affecting food intake in cancer [11,46]

Chapter 5.18

Table 5.18.1 Nutrition interventions in palliative care

Table 5.18.2 Recommended approach for patients with advanced dementia or near end‐of‐life conditions considering long‐term enteral nutrition access devices

List of Illustrations

Chapter 1.1

Figure 1.1.1 Diagnosis tree for undernutrition. COPD, chronic obstructive pulmonary disease.

Chapter 1.3

Figure 1.3.1 The social determinants of health.

Figure 1.3.2 Range of factors influencing food choice.

Chapter 2.1

Figure 2.1.1 Summary of framework to facilitate nutritional screening tool selection

Figure 2.1.2 Summary of the factors that can influence rates of nutritional screening

Chapter 2.4

Figure 2.4.1 Protocol for the avoidance of the refeeding syndrome in patients on enteral or parenteral nutrition (adults only).

Chapter 2.7

Figure 2.7.1 Imaging techniques available for the assessment of body composition. (a) CT/MRI image. (b) Dual‐energy X‐ray absorptiometry (DXA) examination. (d) shows stages in generation of 3D outputs from reconstruction to creation of raw image, and measurement of key body landmarks. Open access images extracted from: Wells JCK, Stocks J, Bonner R, et al. Acceptability, precision and accuracy of 3D photonic scanning for measurement of body shape in a multi‐ethnic sample of children aged 5–11 years: the SLIC Study.

PloS One

2015;

10

(4): e0124193.

Chapter 3.3

Figure 3.3.1 Relationship between nitrogen balance and nitrogen intake. Results of a meta‐analysis of 19 studies involving 235 individuals. Each point represents an individual subject’s observed response to a specific intake.

Chapter 4.4

Figure 4.4.1 Gastrointestinal access for enteral nutrition.

Chapter 5.1

Figure 5.1.1 Progression of undernutrition with associated short‐term and long‐term consequences.

Figure 5.1.2 Timing of growth of body systems during childhood.

Chapter 5.5

Figure 5.5.1 International standards for neurological classification of spinal cord injury.

Figure 5.5.2 International standards for neurological classification of spinal cord injury.

Figure 5.5.3 Spinal Nutrition Screening Tool

Chapter 5.6

Figure 5.6.1 Disease‐related undernutrition.

Chapter 5.8

Figure 5.8.1 Algorithm for pancreatic enzyme replacement therapy in CP.

Figure 5.8.2 Algorithm for the nutritional management of chronic pancreatitis.

Chapter 5.10

Figure 5.10.1 Distal feeding algorithm.

Chapter 5.17

Figure 5.17.1 Management algorithm for cancer cachexia [6]

Guide

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Advanced Nutrition and Dietetics in Nutrition Support

 

Edited by

Mary Hickson PhD RD

Sara Smith PhD RD

 

 

 

Series Editor

Kevin Whelan PhD RD FBDA

 

 

 

 

 

 

 

 

 

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ADVANCED NUTRITION AND DIETETICS BOOK SERIES

Nutritional interventions need to be based on solid evidence, but where can you find this information? The British Dietetic Association and the publishers of the Manual of Dietetic Practice present an essential and authoritative reference series on the evidence base relating to advanced aspects of nutrition and dietetics in selected clinical areas. Each book provides a comprehensive and critical review of key literature in the area. Each covers established areas of understanding, current controversies and areas of future development and investigation, and aims to address key themes, including:

mechanisms of disease and its impact on nutritional status, including metabolism, physiology and genetics

consequences of disease and undernutrition, including morbidity, mortality and patient perspectives

clinical investigation and management

nutritional assessment, drawing on anthropometric, biochemical, clinical and dietary approaches

nutritional and dietary management of disease and its impact on nutritional status.

Trustworthy, international in scope and accessible, Advanced Nutrition and Dietetics is a vital resource for a range of practitioners, researchers and educators in nutrition and dietetics, including dietitians, nutritionists, doctors and specialist nurses.

Preface

Undernutrition is a serious condition that occurs when a person’s diet does not contain sufficient energy or nutrients for a healthy and active life. In the past it has been termed malnutrition, but with the rise of obesity and conditions related to overnutrition, it is important to make a clear distinction between the two extremes. This book focuses particularly on undernutrition in economically developed regions of the world, and as such does not cover in any detail undernutrition relating to famine, conflict and long‐term food insecurity prevalent in developing countries.

Undernutrition can result from inadequate consumption of nutrients, failure to absorb nutrients, impaired metabolism, excessive loss of nutrients or increased requirements. It generally develops gradually but rapid deterioration in nutritional status can occur in acute disease or starvation. The first changes are to nutrient concentrations in blood and tissues, followed by intracellular changes in biochemical functions and structure. Later, overt symptoms and signs appear, enabling diagnosis by history, physical examination, body composition and dietary analysis, and laboratory tests. The causes of undernutrition can be complex and may involve several interacting factors including physiological, psychological, socioeconomic and institutional. The consequences can be far reaching and affect the optimal functioning of individuals, as well as exacerbating and precipitating disease. Undernutrition commonly occurs concurrently with disease and particular life stages make people more vulnerable to it: childhood, during pregnancy and lactation, and during older age.

Advanced Nutrition and Dietetics in Nutrition Support aims to provide an essential and authoritative reference and review of the evidence base relating to undernutrition. It draws on the experience and expertise of recognised authorities from around the world to bring together the information needed by practitioners, researchers and educators in the area of nutrition and diet. Specialist dietitians and nutritionists will find this to be an essential text, but it will also be valuable for doctors, nurses and other health professionals with a specialist interest in nutrition.

The chapters provide a comprehensive and critical review of the key literature and are split into five sections.

The background to undernutrition, which examines in detail the causes and consequences of undernutrition. Chapters cover how and why physiological, psychological, socioeconomic and institutional factors can all play a role in the development of undernutrition, and the consequences of these.

Identification of undernutrition, which covers the range of methods available for screening and assessing levels of undernutrition, including anthropometric, biochemical, clinical and dietary assessment. This section ends with a look at the cutting‐edge advanced imaging techniques now available to assess undernutrition.

Nutritional requirements in nutrition support, which includes fluid, energy, protein, vitamins and minerals in the context of deficiency or when increased requirements exist.

Nutritional interventions to prevent and treat undernutrition, exploring population‐level, community‐wide and institutional interventions, as well as looking in detail at oral, enteral and parenteral approaches to managing individuals.

Undernutrition and nutrition support in a range of clinical specialties. This section incorporates both life stages and clinical conditions where the risk of undernutrition is increased.

The authors have focused on established areas of understanding, current controversies and areas of future development and investigation, and drawn extensively upon the research literature, particularly systematic reviews and meta‐analyses. Efforts have been made to highlight the gaps in the literature and specific issues relating to the quality of the evidence in a given specialty. Importantly, the authors have sought to discuss the implications of research findings for practice and the issues to consider when translating research into practice.

Mary Hickson PhD RDProfessor of DieteticsPlymouth University

Sara Smith PhD RDSenior Lecturer in DieteticsQueen Margaret University

EditorsAdvanced Nutrition and Dietetics in Nutrition Support

This book is the fourth title in a series commissioned as part of a major initiative between the British Dietetic Association and the publishers Wiley. Each book in the series provides a comprehensive and critical review of the key literature in a clinical area. Each book is edited by one or more experts who have themselves undertaken extensive research and published widely in the relevant topic area. Chapters are written by experts drawn from an international audience and from a variety of disciplines as required of the relevant chapter (e.g. dietetics, medicine, biomedical sciences).

The editors and I are proud to present this title: Advanced Nutrition and Dietetics in Nutrition Support. Undernutrition can have profound impacts on a range of outcomes, including clinical (e.g. mortality, morbidity, complications), patient‐centred (e.g. quality of life, patient experience) and economic outcomes (e.g. length of stay, readmission rates, costs). Approaches are needed to both screen and assess undernutrition and to appropriately prevent and manage it, using interventions ranging from public health approaches to parenteral nutrition. We hope that this book will improve health professionals’ understanding and application of nutrition and dietetics in these areas and improve outcomes for the patients affected.

Kevin Whelan PhD RD FBDAProfessor of DieteticsKing’s College LondonSeries EditorAdvanced Nutrition and Dietetics Book Series

Foreword

I am delighted to present the foreword for Advanced Nutrition and Dietetics in Nutrition Support, edited by two eminent British dietitians and clinical nutritionists, Professor Mary Hickson and Dr Sara Smith. Both of the authors have the advantage of considerable clinical and research experience in actually providing nutrition support as well as a gift for communicating their knowledge of the science and art to others. Together with the experts writing each chapter, they nicely define and set out the problem of undernutrition, the tools for deciding what needs to be done and then what to do, all in a single volume.

This is a book that I, and many other practitioners throughout the world, will welcome as an addition to their core reference libraries that they will turn to repeatedly in their daily work because it manages to convey the essentials succinctly and authoritatively. The information it provides is useful not only in Europe but globally since the comprehensive and critical review of the key literature in nutrition support covers not only basic concepts but current controversies and likely directions for future developments in the field.

The book is well suited to both beginners and master practitioners. Early sections provide a succinct background on undernutrition and how to identify it, followed by a section describing nutritional requirements. In addition to artificial nutrition support (e.g. parenteral, enteral), a welcome addition is a chapter on population and community interventions to prevent and treat undernutrition. The various routes that can be used to provide nutritional support have an entire section of their own. A particularly valuable section of the book is its coverage of over a dozen of the most common diseases and conditions requiring nutrition support. They are tackled in sufficient detail to provide the practitioner with the specific considerations to adequately deal with the patient’s problem. Paediatric as well as older adults are considered. In addition to the diseases involving various organ systems and metabolic disease, special and rarely covered problems such as anorexia nervosa, HIV, burns, orthopaedics and spinal cord injury are discussed. The special issues arising in delivering nutrition support in critical care and palliative care are also covered.

I look forward to reading and using this book, and congratulate the authors on a job well done.

Johanna T. Dwyer DSc RD

Professor of Medicine and Community Health, School of Medicine and Friedman School of Nutrition Science and Policy

Senior Nutrition Scientist, Jean Mayer USDA Human Nutrition Research Center, Tufts University

Director, Frances Stern Nutrition Center, Tufts Medical Center, Boston, USA

Editor biographies

Mary Hickson

Mary Hickson is Professor of Dietetics at the University of Plymouth, UK, and leads the Dietetics, Human Nutrition and Health Research group in the Institute of Health and Community. Her research interests include sarcopenia and frailty, hospital nutritional care, and nutrition in older people. Professor Hickson is on the editorial board of the Journal of Human Nutrition and Dietetics.

Sara Smith

Sara Smith is a Senior Lecturer in Dietetics and Nutrition at Queen Margaret University in Edinburgh, Scotland, UK. She is particularly interested in nutritional assessment, undernutrition and the effects of treatment interventions on nutritional status. Her own PhD explored the effects of an intradialytic exercise programme on quality of life, functional and nutritional status of individuals receiving haemodialysis therapy. Dr Smith works with the National Health Service in a number of capacities and is actively engaged in the work of the British Dietetic Association. She won the BDA IBEX award in 2016 in recognition of her significant contribution to the dietetic profession.

Kevin Whelan

Kevin Whelan is the Professor of Dietetics and Head of Department of Nutritional Sciences at King’s College London. He is a Principal Investigator leading a research programme exploring the interaction between the gut microbiota, diet in health, disease and in patients receiving artificial nutrition support. In 2012 he was awarded the Nutrition Society Cuthbertson Medal for research in clinical nutrition and in 2017 was appointed a Fellow of the British Dietetic Association. Professor Whelan is on the editorial boards of Alimentary Pharmacology and Therapeutics and the Journal of Human Nutrition and Dietetics.

Contributors

Christine Baldwin PhD RDLecturer in Nutrition and DieteticsKing’s College LondonLondon, UK

Stephanie Baron PharmD PhDEuropean Hospital Georges‐PompidouParis, France

Danielle Bear MRes RDHEE/NIHR Clinical Doctoral Research FellowGuy’s and St Thomas’ NHS Foundation TrustLondon, UK

Jack J. Bell PhD AdvAPDSenior Dietitian and Research FellowPrince Charles HospitalBrisbane, Australia

Timothy Bowling MD FRCPConsultant in Gastroenterology and Clinical NutritionNottingham University Hospitals NHS TrustNottingham, UK

Katrina Campbell PhD AdvAPDAssociate Professor of Nutrition and DieteticsBond UniversityRobina, Australia

Stefan G.J.A. Camps PhDResearch FellowNational University of SingaporeSingapore

Peter F. Collins PhD APDSenior Lecturer in Nutrition and DieteticsQueensland University of TechnologyBrisbane, Australia

Avril Collinson PhD RDAssociate Professor in DieteticsPlymouth UniversityPlymouth, UK

Kevin Conlon MD FRCSIProfessor of SurgeryTrinity College DublinDublin, Ireland

Clare Corish PhD RD FINDIAssociate ProfessorUniversity College DublinDubin, Ireland

Marie Courbebaisse MD PhDAssociate ProfessorEuropean Hospital Georges‐PompidouParis, France

Alison Culkin PhD RDResearch DietitianSt Mark’s HospitalHarrow, UK

Ronit Das MBBS MRCPGastroenterology RegistrarRoyal Derby HospitalDerby, UK

Sinead N. Duggan PhDPostdoctoral Research DietitianTrinity College DublinDublin, Ireland

Alastair Duncan PhD RDPrincipal Dietitian and Lecturer in NutritionGuy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondon, UK

Sarah A. Elliott PhDPostdoctoral Research FellowUniversity of AlbertaEdmonton, Canada

Peter W. Emery PhDProfessor of Nutrition and MetabolismKing’s College LondonLondon, UK

Lisa Chiara Fellin PhDSenior Lecturer in PsychologyUniversity of East LondonLondon, UK

Alastair Forbes MDProfessor of MedicineUniversity of East AngliaNorwich, UK

Laura Frank PhD RDNClinical DietitianMulticare Health SystemTacoma, USA

Gérard Friedlander MD PhDProfessor of PhysiologyEuropean Hospital Georges‐PompidouParis, France

Maria Gabriella Gentile PhDFormer DirectorEating Disorders UnitArese, Italy

Filomena Gomes PhD RDNutrition Postdoctoral ResearcherCereneo AG and Kantonsspital AarauVitznau, Switzerland

Sue M. Green PhD RNAssociate Professor of NursingUniversity of SouthamptonSouthampton, UK

George Grimble PhDPrincipal Teaching FellowUniversity College LondonLondon, UK

Rosemary Hayhoe RDClinical DietitianSunnybrook Health Sciences CentreToronto, Canada

C. Jeyakumar Henry PhDDirector of the Clinical Nutrition Research CentreNational University of SingaporeSingapore

Mary Hickson PhD RDProfessor of DieteticsPlymouth UniversityPlymouth, UK

Marc Jeschke MD PhD FACSProfessorUniversity of TorontoSunnybrook Health Sciences CentreToronto, Canada

Matthieu Joerger MDMedical Resident, Nutritional Support UnitArchet University HospitalNice, France

Anna Julian MNutr RDResearch DietitianImperial College LondonLondon, UK

Katie Keetarut MSc RDSpecialist Dietitian for IBDUniversity College London HospitalLondon, UK

Lynne Kennedy PhD RNutr (Public Health)Professor of Public Health and NutritionUniversity of ChesterChester, UK

Ronald L. Koretz MDEmeritus Professor of Clinical MedicineUCLA School of MedicineLos Angeles, USA

Eve M. Lepicard PhDScientific DirectorInstitute for European Expertise in PhysiologyParis, France

Callum Livingstone PhD FRCPathConsultant Chemical PathologistRoyal Surrey County Hospital NHS TrustGuildford, UK

Miranda Lomer MBE PhD RDSenior Consultant Dietitian and Reader in DieteticsGuy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondon, UK

Angela Madden PhD RD FBDAPrincipal Lecturer in Nutrition and DieteticsUniversity of HertfordshireHatfield, UK

Katelynn Maniatis MHSc RD CNSCClinical DietitianSunnybrook Health Sciences CentreToronto, Canada

Luise Marino PhD RDLead Paediatric DietitianUniversity Hospital Southampton Foundation TrustSouthampton, UK

Hilary McCoubrey MSc RDSpecialist Diabetes DietitianBirmingham Women’s and Children's HospitalBirmingham, UK

Rosan Meyer PhD RDHonorary Senior LecturerImperial College LondonLondon, UK

Joao F. Mota PhDAdjunct ProfessorFederal University of GoiásGoiânia, Brazil

Paula Murphy PhD RDNutrition Support DietitianDerriford HospitalPlymouth, UK

Pinal S. Patel PhD RDSpecialist Dietitian for Intestinal FailureUniversity College London HospitalLondon, UK

Emily Player MBBSGastroenterologistNorfolk and Norwich University HospitalNorwich, UK

Carla M. Prado PhD FTOSCAIP Chair in Nutrition, Food and HealthUniversity of AlbertaEdmonton, Canada

Claire E. Robertson PhD RNutrSenior Lecturer in Nutrition and Public HealthUniversity of WestminsterLondon, UK

Kathryn Rochette MEd RDClinical DietitianSunnybrook Health Sciences CentreToronto, Canada

Mary Krystofiak Russell MS RDN FANDSenior Manager for US NutritionBaxter Healthcare CorporationDeerfield, USA

Stéphane M. Schneider MD PhD FEBGHProfessor of NutritionArchet University HospitalNice, France

Denise Baird Schwartz MS RD FANDNutrition Support Co‐ordinatorProvidence Saint Joseph Medical CenterBurbank, USA

Shahriar Shahrokhi MD FRCSC FACSAssistant ProfessorUniversity of TorontoSunnybrook Health Sciences CentreToronto, Canada

Clare Shaw PhD RDConsultant DietitianRoyal Marsden NHS Foundation TrustLondon, UK

Sara Smith PhD RDSenior Lecturer in DieteticsQueen Margaret UniversityEdinburgh, UK

Alan Torrance MScFormerly, Head of Newcastle NutritionRoyal Victoria InfirmaryNewcastle upon Tyne, UK

Liesl Wandrag PhD RDPrincipal Critical Care DietitianGuy’s and St Thomas’ NHS Foundation TrustLondon, UK

Kevin Whelan PhD RD FBDAProfessor of DieteticsKing’s College LondonLondon, UK

Lisa Wilson PhD RPHNutrPublic Health Nutrition ConsultantMiddlesex, UK

Samford Wong BSc RDLead Dietitian in Spinal InjuriesNational Spinal Injuries CentreAylesbury, UK

Alison Woodall PhD RDSenior Lecturer in Nutrition and DieteticsUniversity of ChesterChester, UK

Adrienne Young PhD APDSenior DietitianRoyal Brisbane and Women’s HospitalBrisbane, Australia

Abbreviations

ACCP

American College of Chest Physicians

AD

autonomic dysreflexia

ADL

activities of daily living

AEE

activity‐induced energy expenditure

AI

adequate intake

AIDS

acquired immune deficiency syndrome

AIS

ASIA Impairment Scale

AKI

acute kidney injury

ALS

amyotrophic lateral sclerosis

AMA

American Medical Association

AN

anorexia nervosa

AP

acute pancreatitis

APACHE

Acute Physiological and Chronic Health Evaluation

ARR

absolute risk reduction

ASPEN

American Society for Parenteral and Enteral Nutrition

BANS

British Artificial Nutrition Survey

BAPEN

British Association for Parenteral and Enteral Nutrition

BCAA

branched chain amino acid

BDA

British Dietetic Association

BIA

bioelectrical impedance analysis

BMD

bone mineral density

BMI

body mass index

BMR

basal metabolic rate

BW

body weight

CCK

cholecystokinin

CHF

chronic heart failure

CI

confidence interval

CKD

chronic kidney disease

CMV

cytomegalovirus

COMA

Committee on the Medical Aspects of Food and Nutrition Policy

COPD

chronic obstructive pulmonary disease

CP

chronic pancreatitis

CRP

C‐reactive protein

CT

computed tomography

CVD

cardiovascular disease

DAFNE

Dose Adjustment for Normal Eating

DEXA (DXA)

dual‐energy x‐ray absorptiometry

DIT

diet‐induced thermogenesis

DRI

Dietary Reference Intake

DRV

Dietary Reference Value

DS‐EF

diabetes‐specific enteral formula

DSM

Diagnostic and Statistical Manual

DS‐ONS

diabetes‐specific oral nutritional supplement

EAR

estimated average requirement

EC

European Commission

ECF

extracellular fluid volume

ECG

electrocardiogram

EFSA

European Food Safety Authority

EN

enteral nutrition

EORTC

European Organization for Research and Treatment of Cancer

EPIC

European Prospective Investigation into Cancer

ERAS

enhanced recovery after surgery

ESKD

end‐stage kidney disease

EU

European Union

FAO

Food and Agriculture Organization

FFM

fat‐free mass

FFMI

fat‐free mass index

FFQ

food frequency questionnaire

FINES

French Interdialytic Nutrition Evaluation Study

FM

fat mass

FNB

Food and Nutrition Board

FOOD

Feed Or Ordinary Diet trial

GFR

glomerular filtration rate

GI

gastrointestinal, glycaemic index

GLP‐1

glucagon‐like peptide 1

GRV

gastric residual volume

GSRS

Gastrointestinal Symptom Rating Scale

HAART

highly active antiretroviral therapy

HD

haemodialysis

HGS

handgrip strength

HIV

human immunodeficiency virus

HOPE

Heart Outcomes Prevention Evaluation study

HPN

home parenteral nutrition

HRQL

health‐related quality of life

IBD

inflammatory bowel disease

IBW

ideal body weight

ICD

International Classification of Diseases

ICU

intensive care unit

IDA

iron deficiency anaemia

IDDSI

International Dysphagia Diet Standardization Initiative

IDNT

International Dietetic and Nutrition Terminology

IDPN

intradialytic parenteral nutrition

IDWG

interdialytic weight gain

IF

intestinal failure

IGF

insulin‐like growth factor

IHI

Institute for Healthcare Improvement

IL

interleukin

INR

international normalized ratio

IOM

Institute of Medicine

IU

international unit

IV

intravenous

IVACG

International Vitamin A Consultative Group

JBDS

Joint British Diabetes Society

JCA

jejunocolic anastomosis

JRA

jejunorectal anastomosis

LBM

lean body mass

LCD

low‐calorie diet

LCT

long‐chain triglyceride

LFT

liver function test

LIDNS

Low Income Diet and Nutrition Survey

LOFFLEX

LOw Fat Fibre Limited EXclusion (diet)

LOS

length of stay

LRNI

lower reference nutrient intake

MAI

Mycobacterium avium

complex

MAMC

mid‐arm muscle circumference

MCT

medium‐chain triglyceride

MD

mean difference

MDRD

Modification of Diet in Renal Disease study

MDT

multidisciplinary team

MIS

Malnutrition Inflammation Score

MNA

Mini Nutritional Assessment

MND

motor neuron disease

MRI

magnetic resonance imaging

MS

multiple sclerosis

MST

Malnutrition Screening Tool

MTD

modified‐texture diet

MUAC

mid‐upper arm circumference

MUST

Malnutrition Universal Screening Tool

NaDIA

National Diabetes Inpatient Audit

NAFLD

non‐alcoholic fatty liver disease

NASH

non‐alcoholic steatohepatitis

NB

nitrogen balance

NBD

neurogenic bowel dysfunction

NCPM

Nutrition Care Process and Model

NGT

nasogastric tube

NHANES

National Health and Nutrition Examination Survey

NHPCO

National Hospice and Palliative Care Organization

NICE

National Institute for Health and Care Excellence

NJ

nasojejunal

nPCR

normalized protein catabolic rate

nPNA

normalized protein nitrogen appearance

NRS

Nutritional Risk Screen

NST

nutrition support team

ONS

oral nutritional supplement

OR

odds ratio

PAL

physical activity level

PCP

Pneumocystis

pneumonia

PEG

percutaneous endoscopic gastrostomy

PEI

pancreatic exocrine insufficiency

PEPT1

peptide transporter 1

PERT

pancreatic enzyme replacement therapy

PG‐SGA

Patient‐Generated Subjective Global Assessment

PICC

peripherally inserted central catheter

PML

progressive multifocal leucoencephalopathy

PN

parenteral nutrition

POMC

pro‐opiomelanocortin

PPI

proton pump inhibitor

PTH

parathyroid hormone

PUFA

polyunsaturated fatty acid

PYY

pancreatic peptide YY

QALY

quality‐adjusted life‐year

RCT

randomised controlled trial

RD

registered dietitian

RDA

recommended daily allowance

RDI

recommended dietary intake

REE

resting energy expenditure

RNI

reference nutrient intake

ROS

reactive oxygen species

RR

relative risk

RRT

renal replacement therapy

RTU

ready to use

SACN

Scientific Advisory Committee on Nutrition

SBS

short bowel syndrome

SBS‐QoL

short bowel syndrome quality of life questionnaire

SCI

spinal cord injury

SD

standard deviation

SES

socioeconomic status

SGA

Subjective Global Assessment

SI

small intestine, safe intake

SIRS

systemic inflammatory response syndrome

SNST

Spinal Nutrition Screening Tool

SO

sarcopenic obesity

SOFA

Sequential Organ Failure Assessment

TAG

triacylglycerol

TBSA

total body surface area

TBW

total body water

TEE

total energy expenditure

TGF

transforming growth factor

TNF

tumour necrosis factor

TSF

triceps skinfold

TSH

thyroid stimulating hormone

TUG

timed up and go (test)

UL

upper level

US

ultrasound

USG

urine specific gravity

VLCD

very low‐calorie diet

VRIII

variable‐rate intravenous insulin infusion

WHO

World Health Organization

SECTION 1Background to undernutrition

Chapter 1.1Definitions and prevalence of undernutrition

Mary Hickson1 and Sara Smith2

1 Plymouth University Institute of Health and Community, Peninsula Alllied Health Centre, Plymouth, UK

2 Department of Dietetics, Nutrition and Biological Sciences, Queen Margaret University, Edinburgh, UK

1.1.1 Undernutrition: definition and diagnostic criteria

A universal definition for undernutrition is lacking, but it is generally accepted that malnutrition is defined as ‘a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue and body form (body shape, size and composition) and function and clinical outcome’ [1]. Such a definition refers to both undernutrition and overnutrition; in this book, the term ‘undernutrition’ is used rather than ‘malnutrition’, to distinguish between the issues of undernutrition and overnutrition.

Global consensus work to develop universal diagnostic criteria and documentation for undernutrition is in progress and is led by the world’s four largest parenteral and enteral nutrition societies [2]. The ongoing work recognises the value of unified terminology, which reflects contemporary understanding and practices, to allow global comparisons and improve clinical care [3] and ultimately aims to seek the adoption of consensus criteria by the World Health Organization and the International Classification of Disease. Early discussions have identified that consensus criteria will need to take account of differences in global practices, such as financial reimbursement and the sometimes limited availability of assessment methods in clinical practice to assess body composition, for example fat‐free mass [2].

Diagnostic criteria have generally focused on dietary intake and clinically relevant changes in body mass (e.g. body mass index (BMI) and involuntary percentage weight loss) [1]. However, it is increasingly recognised that criteria should consider additional factors, such as the presence of acute or chronic inflammation and changes in muscle function [2–5]. This more aetiological approach to diagnosis would allow the recognition of important differences in the pathophysiology of undernutrition and potential response to intervention [5]. The assessment of muscle function and inflammatory markers could therefore result in earlier recognition of risk and the implementation of more effective targeted interventions [4].

The European Society of Enteral and Parenteral Nutrition [3] has proposed a more aetiological approach to the diagnosis of different categories of undernutrition (Figure 1.1.1). These categories are disease‐related undernutrition with inflammation, disease‐related undernutrition without inflammation and undernutrition without disease. However, further work is required to agree specific diagnostic indices for each of these categories. Furthermore, it is acknowledged that some patients may present with mixed aetiologies (e.g. disease‐related undernutrition together with economic‐related undernutrition). This book addresses the causes, consequences and management of undernutrition in the categories outlined in Figure 1.1.1, but the focus is on issues arising primarily in economically developed countries. The book does not attempt to explore the wide‐ranging and complex issues surrounding hunger‐related undernutrition in famine or conflict situations found more frequently in developing countries, particularly affecting children.

Figure 1.1.1 Diagnosis tree for undernutrition. COPD, chronic obstructive pulmonary disease.

Source: Adapted with permission of Elsevier from Cederholm et al. [3].

1.1.2 Prevalence of undernutrition

The reported prevalence of undernutrition in hospitals varies widely due to differences in study populations, assessment tools and settings. Interpretation of the data is also complicated by small and unrepresentative sample sizes, single‐centre studies, geographical variations, the use of tools without validation and failure to screen the total population. In Europe, several large studies indicate rates in the range of 20–30%, with a higher prevalence in older adults (32–58%) and in cancer (31–39%). Asian studies show a prevalence of 27–39%, again increasing with age (88%), and higher rates in critically ill (87%), surgical (56%) and gastrointestinal malignancy (48%) populations. Similar prevalence is found North America (37–45%) and Australia (23–42%). Prevalence of undernutrition in Latin American hospitals appears to be slightly higher with most studies indicating rates of 40–60%. Consistent with other countries, rates were higher in gastrointestinal surgery patients (55–66%) and older adults (44–71%) [6].

Over 20 years of data are available in the UK since the seminal paper by McWhirter and Pennington [7] was published, and include a national survey called ‘Nutritional Screening Week’ carried out by the British Association of Parenteral and Enteral Nutrition (BAPEN) over a 4‐year period, controlling for the time of the year [8]. This group of datasets shows similar patterns to those described above and also suggests that there has been little change in prevalence during this time [8]. Data on hospital incidence are completely lacking but are extremely challenging to collect and are unlikely to be available unless routine screening and storing in electronic records become the norm.

One obvious factor that will affect undernutrition is food intake during hospital stay. This has been examined by the ‘Nutrition Day’ survey, which is an annual 1‐day survey of hospital patients’ food intake. These important data show that almost half of all hospital patients (n = 91 245) did not eat a full meal. The factors associated with this lower intake are eating less the week before, physical immobility, female sex, old or young age, and a very low BMI [9]. This suggests that interventions to address poor food intake, targeted at those at risk, will be crucial to reduce prevalence of undernutrition in the future.

The prevalence of undernutrition in other settings has also been examined but far fewer data exist. Nursing and residential homes have reported rates of 17–71% for defined undernutrition and up to 97% for those at risk of undernutrition [10]. The UK Nutrition Screening Week data show rates of 41% with little variation across geographical regions or types of care home [11].

Overall, it is clear that undernutrition commonly occurs concurrently with disease and at particular life stages. It is important to note that the methods used to detect undernutrition in prevalence studies are designed to identify protein and energy undernutrition. The identification of micronutrient deficiencies requires different tools and tests.

Despite decades of identifying undernutrition as a prevalent and problematic condition, it remains an elusive challenge in institutional and community settings. Understanding the causes and consequences of undernutrition is essential to subsequently designing multicomponent approaches to reducing its burden.

References

1. Todorovic V, Russell CA, Elia M. The ‘MUST’ Explanatory Booklet. A Guide to the Malnutrition Universal Screening Tool (MUST) for Adults. Redditch: BAPEN, 2011.

2. Cederholm T, Jensen GL. To create a consensus on malnutrition diagnostic criteria: a report from the Global Leadership Initiative on Malnutrition (GLIM) meeting at the ESPEN Congress 2016.

Clin Nutr

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(1): 7–10.

3. Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, Compher C, Correia I, Higashiguchi T, Holst M, et al. ESPEN guidelines on definitions and terminology of clinical nutrition.

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4. Smith S, Madden AM. Body composition and functional assessment of nutritional status in adults: a narrative review of imaging, impedance, strength and functional techniques.

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5. White JV, Guenter P, Jensen G, Malone A, Schofield M, Academy of Nutrition and Dietetics Malnutrition Work Group, ASPEN Malnutrition Task Force, ASPEN Board of Directors. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition).

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6. Correia MI, Perman MI, Waitzberg DL. Hospital malnutrition in Latin America: a systematic review.

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7. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital.

BMJ

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8. Ray S, Laur C, Golubic R. Malnutrition in healthcare institutions: a review of the prevalence of under‐nutrition in hospitals and care homes since 1994 in England.

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Chapter 1.2Physiological causes of undernutrition

Pinal S. Patel1, Katie Keetarut1 and George Grimble2

1 Department of Nutrition and Dietetics, University College London Hospital NHS Foundation Trust, London, UK

2 Institute of Liver and Digestive Health (Bloomsbury), University College London, London, UK

1.2.1 Altered metabolism

The characteristics of the human gastrointestinal tract

The gastrointestinal (GI) tract has a high degree of latency. Luminal contents may pass the same point several times through the action of motility patterns during the absorptive phase. These intestinal responses to the presence of luminal food operate within the intradiurnal cycle of hunger and satiety. Intestinal regions of differing function follow sequentially and each processes the output of the preceding segment in turn, presenting a suitable output to the succeeding segment. As discussed later, feeding cues stimulate the cephalic phase in order to prepare all regions of the GI tract, liver and endocrine organs to receive a large input and deal with it efficiently at an optimum metabolic cost. The oral intake of food presents a challenge because of the metabolic demand of handling large peripheral substrate loads that are specific according to the nutrient involved. Water and electrolytes pose a special challenge and the primary function of the GI tract is to maintain water and electrolyte balance in concert with the kidney, lungs and sweat glands.

Humans are mixed foregut/hindgut fermenters, deriving approximately 10% of energy intake from colonic microbial metabolism of malabsorbed macronutrients [1]. Humans lie between foregut fermenters (e.g. obligate carnivores), who have a small colon and rapid whole‐GI transit, and hindgut fermenters (e.g. rabbits), whose large colon and slow transit allow colonic salvage of fermented polysaccharides so that over 30% of dietary energy is absorbed as short‐chain fatty acids [1]. Intestinal size across all mammalian species is matched to metabolic mass [2], all other things being equal, and the reserve capacity of the GI tract is sufficient with a safety margin. Key studies of intestinal substrate transporter capacity in rats and mice subject to 25–75% small intestinal resection, or who were kept in cold conditions to stimulate hyperphagia, demonstrated that reserve capacity was approximately 100% [3]. Therefore, efficient assimilation and the high metabolic cost of maintaining the GI tract are balanced. Adaptation to increased nutrient loads can occur. The best human example is the case of Antarctic explorers whose daily oral intake of approximately 5000 kcal comprised 57% fat, 35% carbohydrate and 8% protein [4]. Their dietary fat intake increased from 92 g/day to 320 g/day but digestive and absorptive capacity clearly adapted above the usual safety margin.