ATENEO SCHOOL OF MEDICINE AND PUBLIC HEALTH

NUTRITION GUIDE FOR CLERKS

SCHOOL YEAR 2019-2020

INTRODUCTION:
Malnutrition has measurable and important adverse effects on clinical outcomes. Depletion of lean body
mass due to food reduced intake or increase nutrient requirement due to malabsorption, nutrient loss or
hypermetabolism is exacerbated in the presence of inflammation and immobility, therefore increasing the
risk for malnutrition.

In the hospital setting, malnutrition is associated with increased morbidity, associated with muscle
weakness, decreased immune function, alterations in structure and function of the gut, delayed wound
healing, apathy and depression, reduction of appetite, and higher rates of mortality. As a result, it not only
cost patients their health and quality of life but increases hospital stay and unnecessary costs. (Dieticians
of Canada, 2014)

Considering the impact of malnutrition to the patient’s life, it is important for every medical practitioner to
realize that nutrition is not a supportive measure but rather a direct intervention to help prevent or reverse
malnutrition, to prevent malnutrition related complications, and to improve prognosis in hospitalized
patients. All health care practitioners who are directly involved in patients care, particularly Doctors,
could effectively reduce the burden of malnutrition if we have the skill to identify nutritional risk and
effectively contribute to the nutritional management of our patients in the hospital.

*ASPEN: A Paradigm Shift Toward Etiology-Related Definitions. JPEN, July 2013

Malnutrition has been defined in many ways, varying in terminology and criteria. The American Society
for Parenteral and Enteral Nutrition (ASPEN) and Academy of Nutrition and Dietetics (AND) developed
an etiology-based classification system which recognizes 3 underlying etiologies for malnutrition (as seen

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NUTRITION GUIDE FOR CLERKS
SCHOOL YEAR 2019-2020
in the Figure above). The European Society for Parenteral and Enteral (ESPEN) developed their own
criteria which were based on unintentional weight loss, low BMI (as established by the World, Health
Organization) and decrease fat-free mass based on gender. There was no universal definition of
malnutrition, leading to inconsistencies in the current International Classifications of Diseases (ICD-10).

In January 2016 the Global Leadership Initiative on Malnutrition (GLIM), led by ESPEN leaders engaged
several of the major global clinical nutrition societies to build a global consensus around core diagnostic
criteria for malnutrition in adults in clinical settings. The purpose of this specific initiative is to reach
global consensus on the identification and endorsement of criteria for the diagnosis of malnutrition in
clinical settings.

A 2-step approach for the malnutrition diagnosis was selected. First is screening to identify at risk status
by the use of any validated screening tool, and second, assessment for diagnosis and grading the
severity of malnutrition. Based on GLIM criteria, to diagnose malnutrition at least 1 phenotypic criterion
and 1 etiologic criterion should be present. Once diagnosed with malnutrition, we determine the severity
of malnutrition based on phenotypic criterion.

STEPS IN THE NUTRITION SUPPORT PROCESS

I. Medical and Nutrition History

As medical practitioner we always begin with a complete medical history to identify the conditions,
medications or past medical history that may affect the patient’s nutritional status and current condition.
Take note of conditions or co-morbidities that may alter requirements, digestion, and absorption.

Illnesses can alter the processing or 'metabolism' of nutrients. The rate at which the body processes food
into energy may rise, increasing the demand for nutrients. If this increased demand is not met through the
diet, 'metabolic stress' causes protein stores in the body to be broken down to supply the required
energy, ultimately leading to muscle loss. Many diseases can alter metabolism and increase the risk for
malnutrition.

II. Physical Examination and Biochemical Parameters

Remember that protein energy malnutrition is usually associated with by multiple micronutrient
deficiencies. It is important that we identify micronutrient deficiencies at the early stage since clinical
symptoms appear long after micronutrient deficiencies have developed. However, because early
physical signs are non-specific (i.e. lack of energy, malaise, loss of appetite, insomnia), one has to have
a high index of suspicion for MNDs based on history and physical examination

PHYSICAL SIGNS OF NUTRIONAL DEFICIENCIES

Body Part Signs Deficiencies
Hair Color change Protein-energy
Easy pluckability, sparseness malnutrition
Alopecia
Brittle Biotin, zinc, vitamins A
Dryness and E
Skin Acneiform lesions Vitamin A
Follicular keratosis (scalelike plaques) Vitamin A or essential
Xerosis (dry skin) fatty acids
Ecchymoses; petechiae (hemorrhagic spots) Vitamin A
Thickening and hyperpigmentation of pressure Vitamins C and K
points Niacin

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NUTRITION GUIDE FOR CLERKS
SCHOOL YEAR 2019-2020
Scrotal dermatosis
Niacin and riboflavin
Eyes Pale conjunctiva (pale coloring of eyelid lining and Iron, folate, or vitamin
whites of the eyes) B12
Bitot’s spots (foamy spots on the whites of the eyes)
Conjunctival xerosis (inner lids and whites appear Vitamin A
dull, rough)
Angular palpebritis (corners of eyes are cracked, Vitamin A
red)
Riboflavin and niacin
Mouth Decreased production of salivary fluids Vitamin A
Angular stomatitis (cracked, red, flaky at corner of Vitamin B12
mouth)
Bleeding gums Vitamin C
Cheilosis (vertical cracks of lips) Riboflavin
Tongue Atrophic papillae (smooth, pale, slick tongue) Folate, niacin, riboflavin,
iron, or vitamin B12
Glossitis (red, painful tongue) Folate, niacin, and
Magenta tongue (purplish, red tongue) vitamin B12
Riboflavin
Nails Koilonychia (concave, spoon-shaped) Iron
Extremities Genu valgum or varum (knocked knees or bowed Vitamin D or calcium
legs)
Loss of deep tendon reflexes of lower extremities Thiamin and vitamin B12

Biochemical Data

It is well known that malnutrition leads to a decline in immune function. Other parameters such as
albumin and total lymphocyte count are supportive and are surrogates of malnutrition

Laboratory assays can be used as supportive evidence regarding nutrition status. Indicators such as
leukocytosis, C-reactive protein elevation, cytokines, and hyperglycemia may suggest inflammatory
response. Measurements of serum protein levels are used in conjunction with other assessment
parameters to determine the patient’s overall nutritional status. Serum proteins used in nutritional
assessment include, albumin and pre-albumin. All tests, however, have their limitation.

Function Interpretation Recommendation for use

Albumin Maintain osmotic Indicator of inflammation
pressure Proxy measure for underlying
Negative acute-phase injury, disease or inflammation
reactant A predictor for morbidity and
Half-life: 14-20 days mortality
Reflection of acute phase
response
Pre-albumin Major plasma protein Sensitive to short-term
Plays a role in changes in inflammation
metabolism of Affected by hydration, infection,
Vitamin A disease, and other
inflammatory conditions
as an indicator of Nutrition
Status
Does not accurately
represent nutrition status
in ICU setting
Not reliable marker of
nutrition status in the ICU
Does not accurately
represent nutrition status
in ICU setting

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NUTRITION GUIDE FOR CLERKS
SCHOOL YEAR 2019-2020
Negative acute-phase
reactant
Half-life: 2-3 days
C-reactive Has proinflammatory Assists in evaluation of Not used as surrogate
protein and anti-inflammatory inflammatory conditions alone marker of nutrition status
roles with negative acute-phase (Usually used as a
Positive acute-phase reactants marker of inflammation)
reactant Has proinflammatory and anti-
inflammatory roles
White blood Found in the Assists in evaluation of Inflammatory marker
Cells lymphatic system. inflammatory conditions among
with the negative acute-phase
reactants
Total WBC count x 1000 x TLC is an indicator of immune May correlate with the
Lymphocyte percent lymphocyte function that reflects both B nutritional state but is not
Count (TLC) (expressed as a cells and T cells. reliable in those with
decimal) Measure of the immune severe inflammation and
function which declines in the in specific conditions.
presence of malnutrition

III. Nutrition Screening and Assessment

• Screening is the first step in the nutrition process. Nutrition screening and assessment are
integral tools used to direct the nutrition care of a patient. The goal is to identify malnutrition or
the risk for malnutrition.
• General parameters used in nutrition screening include:
o BMI (Is the BMI <20.5?)
o Unintentional weight loss (Is there unintentional weight loss within the last 3 months?)
o Reduced dietary intake (Is there reduced dietary intake in the last week ?)
o Severity of illness (Is the patient severely ill (in the ICU?)
If the answer is “yes” to ANY question, then a more thorough nutrition assessment must
be done to assess the severity of illness and the appropriate nutrition care plan
• General parameters for nutrition assessment include:

GLIM’s diagnostic scheme for screening, assessment, diagnosis, and grading of malnutrition. This is a
high priority because this classification scheme guides clinical diagnosis and reimbursement across much
of the world.

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NUTRITION GUIDE FOR CLERKS
SCHOOL YEAR 2019-2020

STEP 1: SCREENING (See worksheet)

• Screening is the first step in the nutrition process. Nutrition screening and assessment are
integral tools used to direct the nutrition care of a patient. The goal is to identify malnutrition or
the risk for malnutrition.
• General parameters used in nutrition screening include (See worksheet STEP 1A):
o BMI (Is the BMI <20.5?)
o Unintentional weight loss (Is there unintentional weight loss within the last 3 months?)
o Reduced dietary intake (Is there reduced dietary intake in the last week ?)
o Severity of illness (Is the patient severely ill (in the ICU?)
If the answer is “yes” to ANY question, then a more thorough nutrition screening must be done
taking into consideration the nutrition status and the severity of illness that will warrant an
appropriate nutrition care plan (STEP 1B)
o Nutritional risk is defined by the nutritional status and increased requirements caused by
stress metabolism of the clinical condition. Get the Total score which is the sum of
scores for nutrition status and severity of disease. Adjusted if >70 years by adding 1 to
Total Score.
o A nutrition care plan is indicated for patients with a total score > 3

STEP 2: DIAGNOSTIC ASSESTMENT

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NUTRITION GUIDE FOR CLERKS
SCHOOL YEAR 2019-2020

• As alternative to BIA, CTSCAN, or MRI, anthropometric measures such as mid-arm

circumference or calf circumference may be used. Note, however, that there is no standard of
measurements for Filipinos. The cut-off of <35 cm in males and <33 cm in females was adopted
from The Korean Frailty and Aging Cohort Study (KFACS), April 2018
Journal of Korean Medical Science. Cut off for MUAC of <23.5 cm is based on a standard used by
the Vietnamese.

A. Guide to Measuring the calf circumference

1. The subject should be sitting with the left leg hanging loosely or standing with their weight evenly
distributed on both feet.
2. Ask the patient to roll up the pants to uncover the calf.
3. Wrap the tape around the calf at the widest part and note the measurement.
4. Take additional measurements above and below the point to ensure that the first measurement
was the largest.
5. An accurate measurement can only be obtained if the tape is at a right angle to the length of the
calf, and should be recorded to the nearest 0.1 cm.

Measuring Calf Circumference in bed-bound persons

1. Have the person being measured lie in supine position with the left knee bent at 90° angle.
2. Slip a loop of the tape measure around the left calf until largest diameter is located.
3. Pull tape so it is just snug but not so tight that tissue is compressed.
4. Read and accurately record measurement to the nearest 0.1 cm. Repeated measurements should
agree within 0.5 cm.

B. Guide to Measuring the mid-upper arm circumference (MUAC)

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NUTRITION GUIDE FOR CLERKS
SCHOOL YEAR 2019-2020
1. Determine the mid-point between the elbow and the shoulder (acromion and olecranon) as
shown on the picture below
2. Place the tape measure around the LEFT arm (the arm should be relaxed and hang down the
side of the body)
3. Measure the MUAC while ensuring that the tape neither pinches the arm nor is left loose.
4. Read the measurement from the window of the tape or from the tape
5. Record the MUAC to the nearest 0.1 cm or 1mm.

C. Functional assessment such as Hand Grip Strength may be considered as supportive measure
(you may locate the Nutrition Fellows/Clinical Dietitians to borrow their hand dynamometer).
Please follow proper positioning when getting the HGS. Below os the cut-off specific to our Hang
Drip Dynamometer.

Female Weak LOW Normal Male Weak LOW Normal

18-19 < 19.2 +2 18-19 < 35.7 +2
20-24 < 21.5 +2 20-24 < 36.8 +2
25-29 < 25.6 +2 25-29 < 37.7 +2
30-34 < 21.5 +2 30-34 < 36 +2
35-39 < 20.3 +2 35-39 < 35.8 +2
40-44 < 18,9 +2 40-44 < 35.5 +2
45-49 < 18.6 +2 45-49 < 34.7 +2
50-54 < 18.1 +2 50-54 < 32.9 +2
55-59 < 17.7 +2 55-59 < 30.7 +2
60-64 < 17.2 +2 60-64 <30.2 +2
65-69 < 15.4 +2 65-69 < 28.2 +2
70-99 < 14.7 +2 70-99 < 21.3 +2

STEP3: DIAGNOSIS is a high priority because this classification scheme guides clinical diagnosis and
reimbursement across much of the world.

• Meets criteria for malnutrition diagnosis

• GLIM Requires at least 1 phenotypic criterion and 1 etiologic criterion

STEP 4: SEVERITY determined based on Phenotypic criterion

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NUTRITION GUIDE FOR CLERKS
SCHOOL YEAR 2019-2020

Step 5: FINAL DIAGNOSIS includes an etiology-based diagnosis classification which includes

malnutrition related to:
- Chronic disease related malnutrition with inflammation
- Chronic disease related malnutrition with minimal or no perceived inflammation
- Acute disease related malnutrition or injury with severe inflammation
- Starvation related malnutrition including hunger/food shortage associated with socioeconomic
or environmental

Sample Diagnosis: “Acute disease related malnutrition with severe inflammation (moderate risk)”

IV. Management

1. DIAGNOSTIC MANAGEMENT. List the tests/work up necessary to confirm your initial

impression. Include tests that are essential in creating a nutrition care plan.

Sample recommended tests for micronutrient deficiencies

• Anemia: Hemoglobin (Iron, Folic Acid, Vitamin B12, Copper, Zinc deficiency)
• Night Blindness:Serum Retinol (Vitamin A Deficiency)
• Bleeding disorder: INR (Vitamin K Deficiency)
• Osteomalacia: Serum Vitamin D levels (Vitamin D deficiency)
• Goiter: Urinary Iodine (Iodine Deficiency)
Include baseline electrolytes, kidney function, liver function, lipid profile and uric acid, IF NECESSARY.

2. CREATE A NUTRITION CARE PLAN.

In ill patients, nutritional therapy (NT) is an important component of care and seems to positively impact
clinical outcomes. Nutrition and metabolic interventions aim to maintain or improve food intake and
alleviate metabolic derangements, maintain skeletal muscle mass and physical performance, support
medical management and improve quality of life. Given the high incidence of nutritional deficits and
metabolic derangements among our patients, it appears reasonable to assess and monitor relevant
parameters and to initiate interventions early and to prevent excessive deficits. Therefore, the provision
of adequate calories and proteins is important because it can supply substrate for and possibly enhance
acute-phase protein synthetic rates, improving conditions for potential survival.

NUTRITION REQUIREMENTS
Weight to be used is based on BMI.

BMI Weight to Use Equation

Underweight or Normal ABW Weight as measured
Actual Body Weight
Overweight IBW Tannhauser’s Equation:
Ideal Body Weight (Height in cm – 100 – A), where i
A = 10% if small framed,
= 5% if medium framed
= 0% if large framed

Hamwi Equation:
M: 106 lbs for 5 ft + 6lbs /in
F: 100 lbs for 5 ft + 5lbs /in
Obese CBW
Corrected Body Weight [(ABW-IBW) x 0.25] + IBW

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 ATENEO SCHOOL OF MEDICINE AND PUBLIC HEALTH
NUTRITION GUIDE FOR CLERKS
SCHOOL YEAR 2019-2020
Weight to be used in the ICU when weight is not measured:
If phenotype is overweight or obese: Use IBW (look at formula above)
If phenotype is normal or underweight: Use anamnestic weight (Recalled weigh

Factors to consider
Critically ill (Acute Phase)** 15-20 kcal/kg/day ABW
Critically ill (Recovery Phase) 25-30 kcal/kg/day ABW
Calories (per day) Sedentary normal BMI 25-30 kcal/kg/day
*rounded off to hundreds
Underweight (long term goal) 35-40 kcal/kg/day
Obese 14-20 kcal/kg ABW
Non-stressed patient 1-1.5 g/kg/day
Critically ill (Acute Phase)** 1.0-1.2 g/kg/day
Metabolically stressed patient 1.5-2.5 g/kg/day
Proteins (per day) Obese 1.2 g/kg/day or 2 -2.5 g/kg IBW
*rounded off to tens
Predialysis State 0.6 -0.8 g/kg/day**
Hemodialysis 1.1-1.4 g/kg/day**
Micronutrients RDA
General Guide 25-35 ml/kg/day
Congestive heart failure or renal 25 ml/kg/day
disease

Fluids Patients with infection or draining 35 ml/kg/day

wounds
The dietary reference intakes for water in adult males (>19 years) is 3.7 liters
(L)/day while 2.7 L/day in adult females.

• ABW - Actual Body Weight

** ESPEN guidelines 2017

Based on the 2017 ESPEN Guidelines on Clinical Nutrition in the Intensive Care Unit, critically ill
mechanically ventilated patients, EE should be determined by using indirect calorimetry. Hypocaloric
nutrition (not exceeding 70% of EE) should be administered in the early phase (Day 1-2) of acute illness
because early full feeding causes overfeeding as it adds to the endogenous energy production which
amounts to 500-1400 kcal/day. Isocaloric nutrition rather than hypocaloric nutrition can be progressively
implemented after the early phase (Day 3-7) of acute illness. So after day 3, caloric delivery can be
increased up to 80-100% of measured EE.

FEEDING WITH PRECAUTION

In creating a nutrition care plan, it’s important to always assess for risk of refeeding syndrome,
particularly in those with a history of prolonged starvation. We may use the guidelines of the National
Institute for Health and Clinical Excellence for identifying patients at high risk of refeeding problems.

Refeeding refers to the metabolic and physiologic shifts of fluid, electrolytes, and minerals (such as
phosphorus, magnesium, and potassium) that occur as a result of aggressive nutrition support or
nutritional repletion of a malnourished patient (Review physiological changes that lead to refeeding).

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NUTRITION GUIDE FOR CLERKS
SCHOOL YEAR 2019-2020
NICE Guidelines for REFEEDING SYNDROME (Criteria from the guidelines of the National Institute for
Health and Clinical Excellence for identifying at high risk of refeeding problems)

Have one or more of the following:

• BMIlessthan16kg/m2
• Unintentional weight loss greater than 15% in last 3-6 months
• Very little or no nutritional intake for more than 10 days
• Low levels of potassium, phosphate or magnesium prior to feeding

Or two or more of the following:

• BMIlessthan18.5kg/m2
• Unintentional weight loss more than10% in last 3-6mths
• Very little or no nutritional intake for more than 5 days
• History of alcohol abuse, or drugs including insulin, chemotherapy, antacids and diuretics

If patient is assessed to have risk of Refeeding Syndrome, adjust care plan and proceed with precaution
under close monitoring.

o Start nutrition support at 10 kcal/kg/day, increase levels slowly to meet or exceed full
requirements by day 4 to 7
o Restore circulatory volume and monitor fluid balance and overall clinical status closely.
o Provide oral thiamin 200–300 mg daily for 10 days, or full dose daily intravenous vitamin B
preparation for 3 to 5 days. Give a balanced multivitamin/trace element supplement once
daily.
o Provide oral, enteral or intravenous supplements of potassium, phosphate and magnesium
unless pre-feeding plasma levels are high
o Where serum potassium, magnesium or phosphate levels are significantly low, feeding
should NOT be advanced further until supplementation has occurred.

FEEDING PROTOCOL

Achieves > 75% TCR

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NUTRITION GUIDE FOR CLERKS
SCHOOL YEAR 2019-2020

FEEDING DEVICES

FEEDING Length of time Aspiration Risk Type of Tube

< 4 weeks No Nasogastric Tube
ENTERAL FEEDING Short- term Feeding Yes Nasoduodenal tube
Nasojejunal tube
No Surgical Gastrostomy Tube (G-
tube)
>4 weeks Perceutaneous Endoscopic
Long- term Feeding Gastrostomy (PEG)
Peptide based
Yes Jejunostomy (J-tube)
Gastro-jejunostomy (G-J tube)

Methods of delivery

Bolus 100-300 ml feeding delivered in 20 min every 3-4 hours, using a high volume
syringe
100-300 ml feeding delivered in >60 min period every 4 hours (with 1-3 hours
Intermittent interruption in between feedings) OR
16 hr/day continuous feeding with 8 hours interruption
Continuous 10-80 ml/ hour feeding delivered via enteral pump or gravity set

Length of time Limitations Access/ Type

< 10-14 days <900 mOsm/L Peripheral Parenteral Nutrition
PARENTERAL Dextrosity <12g/ml
NUTRITION < 10-14 days >900 mOsm/L Central Parenteral Nutrition
Dextrosity <12g/ml

DISEASE STATE CONSIDERATION

The next step is to individualize a patient's nutritional requirements with regard to any concurrent disease
states. Taking into consideration the disease, identify specific needs of your patients. (e.i. Protein
adjustment if with renal disease, provision of specialized proteins for liver failure)

3. MONITORING AND LONGTERM CARE:

Individualized medicine and tailored nutrition therapy is necessary for our patients. The provision of
diagnostic and therapeutic support is fundamental to the care pathway of patients, particularly those
critically ill. Patients with critical care needs are frequently intubated and intubation, by itself, can impair
swallowing over a period of up to three days post extubation (in patients with no other cause for
dysphagia). Monitoring and documentation of nutritional intake may facilitate early problem identification.

In those identified as malnourished or at risk for malnutrition, counselling, nutrition build up and
monitoring are essential to improve outcome and quality of life. For those with chronic lifestyle diseases
(hypertension, diabetes, metabolic syndrome or obesity) and/or end-organ complications secondary to
lifestyle disease, nutrition counseling and tertiary prevention must be included in long term management.

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NUTRITION GUIDE FOR CLERKS
SCHOOL YEAR 2019-2020
References:
Jensen, GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical
Nutrition Community, Jan 2019
ASPEN Nutrition Support Practice Manual 2nd Ed., 2005
ASPEN Nutrition Support Core Curriculum: A case based approach – the adult patient. 2007/2018
ESPEN guidelines on ICU, 2017
Harrison’s Principles of Internal Medicine, 19th ed. (2015)
CDC Defining Malnutrition
Nice Guidelines: Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral
nutrition

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