Protein-calorie malnutrition: Clinical sciences

Chapters:

Watch video only

Introduction0:00–0:28

Protein-calorie malnutrition occurs when someone loses weight, due to inadequate protein and calorie intake. Diagnosis and management of protein-calorie malnutrition are crucial, particularly in the elderly, as it is associated with poor outcomes.
The most common causes of protein-calorie malnutrition are chronic conditions, oropharyngeal conditions, gastrointestinal malabsorption, anorexia nervosa, as well as social functional barriers.When a patient presents with chief concerns suggesting protein-calorie malnutrition, the first step is to perform a focused history and physical exam.

Stable Patient0:28–2:02

The most important history findings typically include reduced food intake, weight loss, weakness, and fatigue. Your patient may also have a background of chronic diseases, such as chronic kidney disease, COPD, congestive heart failure, or malignancy.
Their physical examination will show thin, dry skin; hair thinning or loss; temporal wasting; muscle atrophy, and generalized muscle weakness.
Additionally, there might be peripheral edema due to a decrease in serum albumin and a subsequent drop in oncotic pressure.
If your patient presents with these symptoms and signs, you should suspect protein-calorie malnutrition. Your next step is to obtain the patient’s weight to calculate their Body Mass Index or BMI.
If the patient’s unable to stand on the scale, such as patients using a wheelchair, you should estimate the patient’s muscle mass by measuring the circumference of your patient’s upper arm.Now, here’s a high-yield fact to keep in mind!
Mean upper arm circumference, or MUAC for short, is measured at the patient’s left upper arm. You can use it to track the patient’s muscle mass loss or gain, just as you can use their weight to follow their weight loss or gain.
An upper arm circumference of less than 22 cm for women and less than 23 cm for men suggests malnutrition.Okay, your next step is to assess if your patient meets the diagnostic criteria for protein-calorie malnutrition.

GLIM Criteria2:02–3:26

One handy tool you can use is the Global Leadership Initiative on Malnutrition, or GLIM, which is a screening survey used in primary care to identify patients who are at risk of malnutrition.
The GLIM criteria are grouped into two main categories called phenotypic and etiologic criteria. Phenotypic criteria include unintentional weight loss greater than 5 percent within the past 6 months, or greater than 10 percent beyond 6 months; a BMI of less than 20, if your patient is less than 70 years old, or less than 22 if your patient is greater than 70 years old; and evidence of reduced muscle mass.
On the flip side, etiologic criteria include reduced food intake for more than 2 weeks; having a condition that reduces caloric absorption; or having a chronic illness that causes chronic or recurrent inflammation, like chronic kidney disease, COPD, congestive heart failure, and malignancy.If your patient meets no phenotypic and etiologic criteria, the GLIM criteria for malnutrition are not met, so you should consider alternative diagnoses.
On the other hand, if your patient has one or more phenotypic criteria, and one or more etiologic criteria, you can diagnose protein-calorie malnutrition.Once you diagnose protein-calorie malnutrition, you should assess the underlying cause.

Chronic Disease3:26–5:03

Underlying causes include; chronic disease, oropharyngeal condition, gastrointestinal malabsorption, anorexia nervosa, and social or functional barriers.Let's start with chronic diseases.
If your patient has a history of known chronic illness, such as advanced dementia, malignancy, autoimmune disease, COPD, chronic kidney disease, or AIDS, diagnose your patient with protein-calorie malnutrition due to an underlying chronic disease.
In such cases, treatment includes optimizing the management of the underlying disease, adding dietary supplementation such as whey powder or high protein drinks, and loosening any dietary restrictions that might be inhibiting adequate caloric intake.
Let’s take an example of a patient with this type of malnutrition, with a background of diabetes mellitus. The treatment approach might involve transitioning them from an ADA diet to a regular diet and adjusting their medications to support weight gain while ensuring good blood sugar control.Now, here’s a high-yield fact to keep in mind!
Chronic conditions cause malnutrition through two main mechanisms. First, there is inadequate food intake, and second, there is the hypermetabolic state created by the underlying inflammation or neoplastic process.
For example, a patient with COPD experiences difficulty in eating due to shortness of breath. Additionally, the extra effort required for breathing may lead to higher calorie expenditure.

Oropharyngeal Condition5:03–5:37

Alright, now let's look at oropharyngeal causes. If your patient has oral pain, poorly fitting dentures, or chewing difficulties, you should assess the patient’s dentition and swallowing function.
If the evaluation reveals abnormal dentition or abnormal swallowing findings, diagnose your patient with protein-calorie malnutrition due to an oropharyngeal condition.
In this case, management includes treatment of the oropharyngeal condition, and providing dietary supplementation. In addition, some patients may benefit from Speech and Swallowing Rehabilitation.On the other hand, if your patient reports abdominal discomfort, abdominal bloating, and diarrhea, you should suspect gastrointestinal malabsorption.

Gastrointestinal Malabsorption5:37–6:39

In this case, you should order labs, including serum CMP, B12, and iron levels, as well as celiac disease antibody testing, and stool studies for fecal fat.
You may also need to order diagnostic testing, such as an upper endoscopy with biopsies. Labs will typically reveal low albumin, B12, and iron levels, as well as electrolyte abnormalities.
In certain patients, there might also be positive celiac disease antibody results; or an elevated fecal fat level. In some individuals, endoscopy with biopsy could reveal mucosal abnormalities.
If you have these findings, diagnose protein-calorie malnutrition due to gastrointestinal malabsorption. Treatment involves addressing the underlying cause and providing dietary supplementation.Some patients can report intentional reduced food intake, fear of gaining weight, as well as distorted perception of their weight.
In this case, your patient’s with protein-calorie malnutrition could be due to anorexia nervosa. Treatment is primarily based on psychotherapy and nutrition counseling, but, in severe cases, you might need to hospitalize the patient!Finally, if your patient reports geographical isolation, transportation barriers, functional limitations, or financial barriers to obtaining or preparing food, diagnose protein-calorie malnutrition due to social or functional barriers.

Anorexia Nervosa6:39–7:01

In such cases, request social services to help the patient obtain shopping, financial, or transportation assistance.Alright, as a quick recap… Protein-calorie malnutrition is defined as weight loss due to inadequate caloric intake.

Social or Functional Barriers7:01–7:22

The diagnosis is based on identifying phenotypic and etiologic factors consistent with the GLIM criteria. If your patient meets the criteria, diagnose protein-calorie malnutrition and then assess for the underlying cause.

Review7:22–8:05

The most common underlying causes to consider include underlying chronic disease, oropharyngeal conditions, gastrointestinal malabsorption, anorexia nervosa, as well as social or functional barriers.
Treatment for protein-calorie malabsorption is primarily based on identifying and treating the underlying condition, providing nutritional supplementation, and correcting the patient’s functional difficulties.
disease oropharyngeal conditions gastrointestinal malabsorption anorexia nervosa as well as social or functional barriers Treatment for protein calorie malnutrition is primarily based on identifying and treating the underlying condition providing nutritional supplementation and