Adult malnutrition can be diagnosed using criteria that evaluate insufficient energy intake, weight loss, loss of muscle mass, fluid accumulation, and diminished handgrip strength. New criteria also consider acute and chronic inflammation. Common causes of malnutrition include medical issues like inflammatory bowel disease, celiac disease, short bowel syndrome, and liver disease. Age-related physiological changes can also increase risk by impairing digestion and absorption of nutrients. Proper nutrition management depends on the condition and may involve dietary modifications, oral supplements, tube feeding, or parenteral nutrition.

1. ADULT MALNUTRITION
PRESENTERS; LILIAN NYONYO
MARGARET KISUNJE
FACILITATOR; DR PAULINA MANYIRI

2. • DIAGNOSTIC CRITERIA FOR MALNUTRITION(ASPEN 2014 and
academy of nutrition and Dietetics)
• Two or more of the following six characteristics:
• Insufficient energy intake
• Weight loss
• Loss of muscle mass
• Loss of subcutaneous fat
• Localized or generalized fluid accumulation that may mask weight loss
• Diminished functional status as measured by handgrip strength.

3. • New criteria 2018 by GLIM it included an appreciation of the role of
acute and chronic inflammation.
• The diagnosis required the combination of at least one phenotype
and one etiologic criteria:
• PHENOTYPE CRITERIA-non volitional weight loss, low body mass
index, or reduced muscle mass.
• ETIOLOGIC CRITERIA-reduced food intake or absorption or underlying
inflammation due to acute or chronic disease.

4. • After making the diagnosis of malnutrition a more compressive
assessment by using the SUBJECTIVE GLOBAL ASSESSMENT (SGA) can
be used.
• But there are other screening elements and tools for nutritional
status which can be used eg; The Nutritional Risk Screening 2002 has
2 components , The Simplified Nutrition Assessment Questionnaire
(SNAQ), MNA-SF (mini nutritional assessment short form ),
MUST(malnutrition universal screening test).

5. PREVALENCE
• Prevalence of malnutrition, however, strongly depends on the setting,
underlying or accompanying diseases as well as on screening and
assessment methods.
Prevalence data of malnutrition and nutritional risk in older adults
across different healthcare settings showed a wide range of
malnutrition from 3% in the community setting to approximately 30%
in rehabilitation and subacute care, even though the review only
included studies using the MNA

6. Determinants
• In industrial countries, disease is one of the most common reasons
for developing malnutrition and the onset of malnutrition can be both
acute and slow.
• Age in itself is an established non-modifiable risk factor for
malnutrition. Higher age is associated with physiological changes
which can potentially slowly result in or further malnutrition such as
impaired taste and smell, decreased gastric flexibility, reduced
appetite, etc.

7. Modifiable determinants
• Targeting these risk factors is a fundamental element in the
prevention and treatment of malnutrition.
• A recent meta-analysis investigated which factors are associated with
incident malnutrition and identified marital situation, hospitalisation
and physical limitations as the most important predictors.
• NON MODIFIABLE
• Physiological factors which may precipitate malnutrition in higher age
include sensory impairment such as diminished taste or olfactory
dysfunction, delayed gastric emptying, and disturbed motility leading
to a functional decline of the ageing gut.

8. • Ageing is therefore also associated with an increase in colonic transit
time, increased intestinal permeability, and, ultimately, altered
intestinal microbiota , which includes loss of biodiversity, enrichment
in opportunistic pathogens, and concomitant reduction of health
associated species, such as short chain fatty acid producing species.

9. Decreased sensory function
• Loss of taste maybe due to a progressive reduction in number of
taste buds per papilla on the tongue while deterioration in sense of
smell maybe associated with changes in olfactory epithelium ,
receptors and neural pathways .
• Some medications may negatively influence taste (e.g antidepressants
and Parkinson’s treatment

10. • Inflammation as a Risk Factor for Malnutrition.
chronic inflammation has long term negative effects on the entire
system. Increasing knowledge indicates that ageing is accompanied by
slightly but chronically elevated inflammation levels.
. This severe systemic inundation of cytokines might be further
triggered by the dysregulated immune system in old age , which is
expressed in an imbalanced homeostasis of pro- and anti-inflammatory
mediators.

11. Changes in the GIT tract
• Gastric acid and pepsin secretion gradually reduce with age, which
can limit the metabolism of certain nutrients such as vitamin B12,
iron and protein .
• There is a decrease in production of saliva in approx 1/3 of people
above 65yrs which slows down peristalsis and increase the likelihood
of constipation
• Slower peristalsis can also delay oesophageal emptying , contributing
to early satiety

12. • Meanwhile, it is widely recognized that inflammation is partly
responsible for triggering many age-related diseases, e.g., Alzheimer’s
Disease , atherosclerosis and cardiovascular events , type 2 diabetes
mellitus , (osteo-) sarcopenia . Therefore, there is considerable
potential that inflammation also contributes to an impaired
nutritional status.
• In the old, increased levels of pro-inflammatory cytokines have early
on been associated with cachexia (“geriatric cachexia”). Cachexia is a
well described complex wasting syndrome which is driven by
inflammation and reflected by a striking loss of skeletal muscle mass
and function.

13. • Inadequate dietary intake
These could be due to; i) social factors,poverty – affecting food
acquisition
Isolation- living alone can typically decrease food enjoyment and caloric
intake

14. Medical and psychiatric factors
 Depression
 Malignancy
 Dysphagia – may occur due to stroke , Parkinson disease, other
motility problems (e.g achalasia, diffuse esophageal spasm,
scleroderma).

15. • Inflammatory Bowel Disease
Can lead to;a) weight loss
Due to inflammation(excessive catabolism, decreased physical activity
and steroid treatment
Loss of lean body mass beyond 10% of their lean body mass is
associated with increased morbidity (e.g poor wound healing and
higher rates of infection after surgery

16. b)Bone disease
Cause is multifactorial , risk factors include glucocorticoid use, disease
related inflammatory activity, malabsorption
c)Micronutrient deficiencies
Related to location and extent of the mucosal inflammation or surgical
resection within the intestinal tract.
i)Terminal ileum – may lead to deficiencies of vitamin B12 or fat
soluble vitamins

17. ii) Proximal small intestine – interferes with iron and calcium
absorption
iii)Diffuse small bowel disease- extensive disease with profuse
diarrhoea may lead to zinc deficiency.
iv) Severe colonic disease may lead to ongoing blood loss and iron
deficiency

18. Nutrition management of IBD
Oral ingestion is preferred , although tube feeding is used when oral
intake is inadequate(nasogastric or nasoduodenal).
We use enteral nutrition supplements to increase calorie and protein
intake for undernourished patients and active disease , patients in
remission but cannot increase caloric intake through a standard diet.
Parenteral nutrition is indicated for patients with short bowel
syndrome, bowel obstruction , patients unable to eat or tolerate tube
feeding

19. Patients with active disease
Dietary modification;- They may benefit from exclusion of gas
producing foods(beans , onions , wheat , alcohol, caffeine), a diet low in
fermentable oligo , di and monosaccharides and polyols , lactose
avoidance .

20. • Celiac disease or gluten-sensitive enteropathy
An immune disorder triggered by an environmental agent (gluten
component of wheat and related cereals) in genetically predisposed
individuals.
Characterized by diarrhea or signs and symptoms of malabsorption(e.g
steatorrhea, weight loss , nutrient or vitamin deficiency).
Extraintestinal – Dermatitis herpetiformis(on elbows, dorsal forearms,
knees, scalp and buttocks), atrophic glossitis .

21. • Dietary management
- Avoiding foods containing wheat , rye and barley
- Diary products to be taken with caution since many patients with
celiac disease can have secondary lactose intolerance.

22. • Short bowel syndrome
Disabling malabsorptive condition resulting from surgical resection for
crohns disease , malignancy , trauma, radiation or vascular
insufficiency.
Has 2 phases ;- Acute phase
Characterized by high intestinal fluid losses and the metabolic
derangement . Starts immediately after resection and generally lasts for
3 to 4 weeks.

23. Management
i) IV fluids with NS and supplemental potassium and magnesium
ii) Acid suppression (H2 receptor antagonist or PPI )

24. -Adaptation phase
Characterized by structural and functional changes to the remaining
small bowel and colon in order to increase nutrient absorption and
slow the gastrointestinal transit( lasts 1 to 2 years).
Management
i) Oral diet – to be transitioned in a slow and stepwise manner over
weeks to months , a diet high in complex carbohydrates and
modest fat is recommended
ii) Fiber supplementation may slow gastric emptying and decrease the
watery nature of stool by absorbing stool water.

25. CAUSES OF MALNUTRITION DUE TO LIVER
DISEASE
• Malnutrition in chronic disease is multifactorial , it can be due to impaired
intake, digestion and absorption of nutritents seen in about 20% of
patients with compensated cirrhosis and in 60% of with advanced disease.
• This can be due to loss of appetite, early satiety due to ascities.
• Low sodium diets can be very unpalatable.
• Also there is degree of maldigestion common in cirrhosis due to decrease
bile salt solubilization, severe maldigestion is common in ALD with
pancreatic damage.
• Malabsorption with or without maldigestion can occur in alcoholics due to
toxic effect of alcohol on small intestinal ultrastructure and brush border
enzymes.

26. • ALD patients also have rapid intestinal transit , increased mucosal
permeability and impaired salt and water absorption
• IMPAIRED NUTRIENT STORAGE
• Loss of storage capacity can exacerbate micronutrient deficiency
caused by low or unbalanced dietary intakes.
• IMPAIRED NUTRIENTS SYNTHESIS AND ALTERED NUTRIENT DEMAND
• Liver cirrhosis particulary affects protein metabolism with reduce
synthesis of transports such as albumin caused by combination of
decreased functional liver mass and alterations of amino acids
demand

27. • Reduced glycogen storage also increases amino acid need for
gluconeogenesis while ongoing inflammation alters the pattern of AA
requirements
• ABNORMAL NUTRIENTS LOSS
• Cirrhotic patients may loose both macro and micronutrients from
diarrhoea or GI blood loss and renal loss of electrolytes are also
higher than normal due to secondary hyperaldosteronism sometimes
exacerbated by diuretics.