Malnutrisi

Konsep Dasar
inadequacy of any nutrient in the diet. Whilst recognised in people with a limited or restricted food intake, it is also associated with excessive food intake. Patients with malnutrition may have evidence not only of protein-energy malnutrition but also of vitamin and mineral deficiencies, especially after major surgery or chronic illness.

Definisi
Malnutrition is caused by an inadequate availability of nutrients, because of either poor intake or deficiency as a result of disease. In developed countries, malnutrition is usually a consequence of disease

Dampak
decreased dietary intake increased nutritional requirements impaired ability to absorb or utilise nutrients
Poor nutrition compromises immune function. Suppression of the immune system by malnutrition has been implicated as one of the major causes of complications in hospitalised patients (Ferguson et al., 1999).

Klasifikasi
Primary malnutrition is seen in those who are dependent upon others for nourishment: infants, children, the elderly, the disabled, prisoners and the mentally ill are the most vulnerable groups. Secondary malnutrition is seen with any disease that disturbs appetite, digestion or the absorption of nutrients. Socioeconomic factors can profoundly influence nutritional status

Konsekuensi
impaired immune function, which increases risk of infection delayed wound healing increased risk of tissue breakdown and pressure ulcers muscle wasting and weakness, which can affect:
respiratory function cardiac function mobility

altered structure of the small intestine (e.g. following surgery), which can result in malabsorption increased risk of post-operative complications apathy and depression general sense of weakness and illness

Specifi c deficiencies Malnutrition may be due to : inadequate energy intake inadequate protein intake inadequate vitamins or minerals

Protein-energy malnutrition
is the inadequate intake of protein, mainly seen in developing countries. Kwashiorkor is the name given to malnutrition resulting from protein deficiency, marasmus is a deficiency of both protein and energy. Kwashiorkor results in: muscle wasting a low serum albumin resulting in peripheral oedema (which may make the muscle wasting less obvious) fatty liver with hepatomegaly.

 Marasmus is due to both protein and energy defi ciencies, which are characterised by the classic features of starvation, including:
growth reduction absence of body fat muscle wasting

Specific vitamin and mineral deficiencies

Vitamin A
The absorption of vitamin A is related to fat absorption in the gut, and requires protein for synthesis. Therefore, a deficiency of fat, protein or a gut-related illness can result in vitamin A deficiency. Deficiency results in growth reduction and visual problems Xerophthalmia may occur in vitamin A deficiency and is characterised by conjunctivitis, abnormal and severe dryness of the surface of the cornea and conjunctiva. Bitots spots (white, soft deposits on the conjunctiva) and night blindness may also occur. Where a deficiency exists, there maybe a reduction in immunity

Good dietary sources of vitamin A (and beta-carotene, a precursor to vitamin A) include

carrots oily fish liver and liver products fortified margarine and fat spreads fish liver oils dairy products (milk, cheese, cream and butter) egg yolks peaches, apricots and mangoes tomatoes and red peppers dark-green leafy vegetables (such as spinach).

Vitamin B1 (thiamine) deficiency

Vitamin B1 deficiency may be seen in individuals who abuse alcohol as, although it is present in many foodstuffs, vitamin B1 is not present in alcohol. In addition, the body does not store vitamin B1, as it is awater-soluble vitamin. Thiamine is mainly required during the metabolism of carbohydrates, fat and alcohol. Diets high in carbohydrate require more thiamine than diets high in fat. The deficiency is commonly known as beriberi.
Dry beriberi refers to the development of neurological problems, such as Wernickes encephalopathy (ataxia, confusion, nystagmus and sixth cranial nerve palsy), peripheral and motor neuropathy. Wet beriberi refers to the development of neurological problems with additional heart failure. The problems are

reversible if suffi cient thiamine is given, intravenously if necessary

Sources
yeast and yeast extract wholegrain cereal foods pork nuts Pulses Cereal

Deficiency Vitamin B2
Vitamin B2 is water-soluble and is found in small amounts in many foods. levels rapidly decrease under serious illness or with the intake of some drugs, for example amitriptyline, imipramine, chlorpromazine or oral contraceptives. A deficiency of riboflavin results in lesions on the mucocutaneous surfaces of the mouth (angular stomatitis, atrophic lingual papillae and magenta tongue), cracked, bleeding lips and glossitis. Itchy perineum and hair loss may be seen. There may also be neurological sequelae with photophobia and ataxia. Ribofl avin deficiency is often accompanied by iron deficiency possibly as a result of impaired absorption

Sources
yeast and yeast extract liver and offal meats green, leafy vegetables eggs milk and dairy products and cereals and cereal products.

Folic acid
Folic acid is the parent molecule of a large number of derivatives collectively known as folates. In deficiency states, it causes megaloblastic anaemia, atrophic tongue and growth retardation. Deficiency is most likely to occur as a result of:
Malabsorption (e.g. in Coeliac disease): The use of certain drugs nterferes with folic acid metabolism (notably methotrexate to treat rheumatoid arthritis and anticonvulsants used in the treatment of epilepsy). Cell proliferation: Some disease states can cause an increase in cell proliferation (e.g. leukaemia).

Sources
liver green vegetables yeast extract pulses some fruits (oranges and orange juice).

Vitamin C (ascorbic acid)

Vitamin C is water-soluble and easily destroyed in cooking. It is biochemically active in collagen synthesis, iron absorption and in immunologic function. a deficiency in vitamin C, better known as scurvy, is characterised by swollen, bleeding gums, wiry hair, anaemia and a predisposition to infections, and easy bruising. people with poor diets devoid of fresh food, and those with increased vitamin C requirements, such as cigarette smokers or post-operativepatients, are likely to have suboptimal levels. Owing to its role in collagen synthesis, adequate vitamin C is essentialfor wound healing.

Sources
fruits and fruit juices (particularly citrus fruits, strawberries, kiwi fruit, berries, currants and guava) some green vegetables (such as green peppers, broccoli, cabbage and spring greens); significant losses can occur during storage and cooking.

Zinc
A deficiency in zinc may occur in patients who require long-term administration of parenteral or enteral feeding, if they have high requirements, with only standard amounts being provided. There are very small body stores of zinc; so problems can arise if it is not present within the diet on a regular basis. Conditions which predispose people to zinc deficiency are related to:
reduced intake (perhaps associated with an eating disorder) reduced absorption/bioavailability (owing to an inhibitor, such as a high-phytate diet) increased losses (such as in diarrhoea or excessive vomiting) increased requirement associated with growth (also in pregnancy/lactation) and are secondary to conditions such as alcoholism.

Sources
red meat fish and shellfish milk and milk products poultry eggs other sources of zinc include bread and cereal products, green, leafy vegetables and pulses, although these all have a lower bioavailability.

Iron
Iron is an essential component of haemoglobin and myoglobin, with its major function being that of carrying oxygen. Many enzymescontain or require iron, and it is required for many metabolic processes. In contrast to other minerals, no mechanism exists in the body to excrete iron, therefore body levels of iron are regulated by absorption.

 Iron deficiency results in a reduced ability to transport oxygen around the body. This can have many harmful effects on cardiovascular and respiratory systems, brain and muscle function, and wound healing. Both a deficiency and excess of iron are associated with an increased susceptibility to infection. Iron deficiency, with or without anaemia, results in a wide range of defects in immune function

Sources
red meat, liver and offal poultry and fish (contain smaller amounts) cereal products and fortified breakfast cereals; these can contribute significant amounts of non-haem iron, but this is less well absorbed than iron from meat products (haem iron).

Manajemen Malnutrisi
a body mass index (BMI) of less than 18.5 kg/m2, or have recently lost more than 10% of their body weight unintentionally,or have a BMI of less than 20 kg/m2, and 5% recent weight loss if the patient has not eaten for fi ve days and is unlikely to eat for at least the next five days has large nutritional losses, is highly catabolic or has a poor absorptive capacity

Nutritional Support
Despite help with and support to eat food whilst in hospital, there will always be a number of patients who, owing to their underlying illness or condition, will require further nutrition support. This maybe either enterally (using supplemented diet, sip feeds or liquid nutrition) or intravenously (using parenteral nutrition).

 Therapeutic feeding will require appropriate line access, whether by a fine-bore nasogastric/nasojejunal feeding tube, percutaneous endoscopic gastrostomy (PEG), or jejunostomy, or by a central catheter for parenteral nutrition (PN).

Nurses role
assessing and monitoring a patients nutritional status. Nutrition screening (Malnutrition Universal Screening Tool, or MUST) Nurses weigh and measure patients, which enables them to calculate a patients BMI. They are also in a key position to ask questions regarding recent weight loss, and appetite and dietary changes.

 During a patients stay in hospital, repeated weights need to be taken, and clearly documented, at regular intervals as weight loss within hospital is common weight measurements will depend upon the patients illness and the acuity of that illness.

 Food- and fluid-intake charts and nutritional care plans frequently need to be implemented by nursing or care staff, as they are the healthcare professionals in most frequent contact with the patient, and are therefore best placed to notice when someone is failing to eat anadequate amount. The nurse is also responsible for facilitating adequate food suitable to the patient, and in a manner that they can take it. It may be necessary to refer to a dietitian or speech and language therapist to achievethis

Catering staff ?
Food needs to be accessible, palatable and nutritious. To achieve this, there needs to be an effective communication channel between Trust management, hospital chefs, dietetic departments, clinical areas and patients so that appropriate meals can be provided 24 hours a day to those that require them.

 Hospital catering is often seen as a Cinderella service, given little respect, only contacted when there is a problem with a meal and often not considered to be involved in patient care, but it has a vital role to play in providing adequate and appealing nutrition for patients often on a budget of less than 22.50 per day per patient.

Dietitians
Dietitians frequently work with catering staff at a strategic level to ensure that the meals provided are healthy and well balanced. Largely, this may be achieved in the planning, monitoring and quality control of menus.

 In selected cases, following referral by a nurse, doctor or speech and language therapist, special diets or support may be required. Referral to a dietitian for those at risk, i.e. with a BMI <18.5 kg/m2, is essential and should be made as soon as possible once all criteria for referral have been met, i.e. the patient has been nutritionallyscreened and action plans within the screening tool have been implemented by nursing staff

 Referral to the dietitian is also recommended for those patients who present with specifi c conditions, such as renal or liver failure, or a non-functioning gut. Dietitians can provide a more formal assessment of nutrition assessment and may use anthropometric measurements to determine, for example, the triceps skin-fold thickness, indicating fat storage, while the mid-arm muscle circumference indicates muscle mass.

Medical staff
The role of the medical practitioner is to recognise the signs of malnutrition through clinical assessment and thorough historytaking and to liaise with other healthcare professionals to organise referrals for further assessment, for example to speech and language therapists, dietitians, clinical psychologists, occupational therapists and the Nutrition Support Team

Managing obese
Obesity does not preclude patients from developing malnutrition, though it may be a natural reaction to think it should. Obese individuals do not usually appear malnourished. The increasing prevalence of obesity in the community suggests that an increasing number of patients admitted to hospital will be obese

 Increased morbidity has been reported in the injured obese patient; this may be related to poor nutrition support. If an obese individual has been trying to lose weight prior to their admission to hospital, this should be an indication that they may be at risk of malnutrition. It can be diffi cult to consume all the essential nutrients (vitamins and minerals) together with adequate protein in an energy-restricted diet

 It can also be difficult to consume all the essential nutrients if the diet mainly consists of high-energy, low-nutrient foods such as fizzy drinks, sweets and cakes rich in fats, oils and sugar. An excess of energy is consumed; the diet may still be deficient in essential nutrients such as minerals, vitamins and essential fatty acids

 In such cases, individuals are consuming adequate energy, although the quality of their diet is poor. This phenomenon has been termed modern malnutrition Although obesity may give an increased chance of survival in situations of starvation, it does not seem to confer the same advantage following injury, when metabolic response is exaggerated in these individuals (Elia, 2003).

Conclusion
It is important to remember that screening will only indicate nutritional risk, not actual nutritional status. The screening process is not a means to an end; it is a way of informing the healthcare practitioner whether a more objective nutrition assessment is required. In hospitals where a thorough nutrition screening process is undertaken on admission and the use of a multidisciplinary approach to nutrition is used, the effects of malnutrition can be minimised. It is important to remember that malnutrition is both a cause and a consequence of ill health.

Referensi
Nutrition: A Handbook for Nurses. 2008. Edited by Carolyn Best. John Wiley & Sons