Treatment and evaluation
If (a high risk of) malnutrition has been established through screening and diagnostics, it is recommended that a dietician be engaged for an extensive nutritional assessment and drawing up a treatment plan. Protocols are available in most healthcare institutions, or agreements have been made about when a dietician can be called in.
NED TIJDSCHR VOOR VOEDING & DIËTETIEK – 2017;72(T).
Treatment adults
Drawing up a treatment plan
The treatment of malnutrition is tailor-made. In order to draw up a good treatment plan, data is collected by the dietitian with regard to a patient’s request for help, motivation and expectations, disease (history) and disorders, metabolic, psychological and social factors.
In addition, a comprehensive assessment of nutritional status is essential, requiring minimal information on:
- food intake, consumption and losses;
- body composition and nutrient reserves;
- functional parameters;
- disease state.
The first three points are part of the nutritional assessment. Information on disease status (metabolic status/inflammation, as an indicator of disease severity) provides additional information on the type of malnutrition.
The dietetic diagnosis is formulated on the basis of the data from the diagnostics . It focuses on the problems in the (under)nutrition field and describes the relationship (cause and effect) with the medical, external and personal factors that influence this. Subsequently, the treatment plan and the treatment goals are determined in consultation with the patient (and possibly next of kin).
Nutritional Needs: Energy, Protein and Micronutrients
An important feature of the treatment for (risk of) malnutrition is striving for sufficient intake of energy (kilocalories/kilojoules) and protein. The aim of this is to stop or limit the loss of muscle mass.
The variation in total energy requirement between patients is large, due to differences in both resting metabolism and energy expenditure due to physical activity and illness. For determining the resting metabolic rate, measurement using indirect calorimetry is preferable to estimating using a formula. Because indirect calorimetry requires specific equipment that is not available in most places, the most common practice among dieticians is formula-based estimation.
The protein requirement depends on age, the amount of lean body mass, amount and type of physical activity, severity of the disease and possible use of corticosteroids. Current recommendations range from 0.8 grams of protein per kilogram of body weight in healthy adults to 1.7 grams (and sometimes even higher) of protein per kilogram of body weight in severe illness.
In a healthy situation, the protein build-up and breakdown are in balance. In illness and aging the balance is negative, among other things:
- insufficient protein intake
- reduced protein utilization (anabolic resistance)
- reduced muscle sensitivity due to inactivity (anabolic resistance)
- increased protein requirement due to inflammation.
- altered digestion and absorption
There is agreement that in these situations more protein is needed than in a healthy situation, regardless of whether someone is malnourished. In general, a minimum amount of 1.2 g protein/kg body weight is adhered to here.
The recommended amounts of micronutrients such as vitamins, minerals and trace elements have been drawn up by the Health Council and are intended for healthy people. Due to a lack of good research it is unclear to what extent there is a changed need for micronutrients during illness. Therefore, in general, the same recommended daily amounts apply during illness as for healthy persons. As part of the diagnosis, the dietitian assesses whether there are risks of micronutrient deficiencies.
More information
Go to the database with energy and protein-rich products.
Dietary foods for medical use
The dietitian will optimize the diet taking into account the patient’s preferences and habits. If the treatment goals cannot be achieved with normal nutrition, the use of diet foods for medical use is indicated, for example protein supplements, medical nutrition, tube feeding, parenteral nutrition (see opposite for more information).
The general rule used here is:
At an intake of 75 – 100% of the established needs, the treatment plan consists of protein- and energy-rich food in the form of fortified main meals, interim provisions and possibly additional medical nutrition or protein supplements.
At an intake of 50% – 75% of the established needs, the advice is medical nutrition and/or tube feeding in addition to protein and energy-rich food.
If the intake is less than 50% of the needs and there is no chance of a rapid improvement in intake, full tube feeding is recommended, supplemented with what is possible per os.
Total parenteral nutrition (TPN) is indicated when sufficient nutrition cannot be provided via the gastrointestinal tract for more than seven days because enteral nutrition is not or insufficiently possible or is contraindicated.
Deviations from the above can be made on the basis of the specific characteristics and individual situation and wishes of the patient.
Refeeding Syndrome
The refeeding syndrome is a complication when initiating nutrition in malnourished patients who have had no oral intake for a long period (>3 days). Recognition and timely intervention is the joint responsibility of the doctor and dietitian. A guideline has been drawn up by the Nederlands Voedingsteam Overleg (NVO) for the prevention and treatment of the refeeding syndrome (see the link to the NVO guideline on the right ) .
Evaluation nutritional status adults
By evaluating, a dietitian determines whether the treatment plan needs to be adjusted. The manner in which and the frequency with which evaluation takes place partly depends on the treatment goals and the severity of malnutrition. The most common methods of evaluating a treatment are:
- Measuring nutritional intake (protein and energy) vs. the nutritional needs;
- Keep track of weight and weight history;
- Measuring muscle mass and strength;
- Determining physical functioning;
- Change in degree of disease/inflammation;
- Change in diet-related complaints.
Achieving balance between nutritional intake and nutritional needs is the most important short-term goal in most cases. Proper measurement of nutritional intake is necessary for this. The ‘Rate & Plate’ method, among others, can be used for this (see opposite for more information).
The frequency of evaluation varies from person to person. In case of serious illness where the (clinical) situation may change rapidly, daily evaluation may be necessary. In the case of less seriously ill and/or more stable people, a dietitian will evaluate how things are going after 1 or more weeks.