Explanation
The main purpose of nutrition management for patients with dysphagia is to prevent aspiration pneumonia by maintaining or improving nutritional status and to promote dysphagia rehabilitation in an effective manner. The long-term aims of nutrition management are to maintain or improve functioning and to maintain or improve quality of life (QOL) through eating orally.
Explanation
To efficiently promote nutrition management based on the status of individual patients, we need to accurately understand their status and the issues they face. We achieve this through nutrition screening and nutrition assessment, which are crucial for devising subsequent nutrition management plans.
Explanation
Nutrition screening is a simple preliminary method of assessing nutrition. In principle, nutrition screening is conducted for all patients in order to identify those with malnutrition or those at risk of malnutrition. Malnutrition includes undernutrition, overnutrition, and metabolic abnormalities; however, for patients with dysphagia, malnutrition typically involves undernutrition.
For patients who are identified in nutrition screening, we need to evaluate the details and degree of their malnutrition (or risk of malnutrition) in detail to determine the cause of the malnutrition; this process is nutrition assessment. The cause of the malnutrition becomes the focus of nutritional intervention. We intergrate multiple pieces of information to obtain an accurate grasp of each patient's nutritional status and disease state and to make a comprehensive assessment.
Explanation
What is required of nutrition screening is for it to place only minimal burden on patients and the assessor and for it be simple and effective. To do this, nutrition screening uses physical measurements such as body weight. This type of measurement provides excellent indicators for quantitatively assessing overall nutritional status and well-suited to current universal assessments. In addition to physical measurements, nutrition screening also incorporates subjective assessments of edema, muscle mass, and subcutaneous fat mass, which are visible indicators of malnutrition. Other indicators sometimes used in nutrition screening include serum albumin (as an indicator of long-term protein metabolism) and grip strength (as a functional indicator of muscle strength).
Explanation
Physical measurements that are the main elements in nutrition screening are taken at sites and on sides that allow us to accurately assess nutritional status based on findings such as palsy and edema. Palsy leads to a decrease in muscle mass, while edema leads to apparent increases in body weight and calf circumference. When we are assessing changes over time, we must be sure to keep the measurement conditions consistent, with all measurements performed by the same person if possible.
Explanation
Physical measurements reflect body fat mass and skeletal muscle mass. Body fat mass can be used to assess energy storage, while skeletal muscle mass can be used to assess protein storage. In undernutrition, both body fat mass and skeletal muscle mass are reduced.
Nutrition assessment is generally intended for people with a body mass index (BMI) < 18.5 kg/m2, which is classified as underweight. For people aged ≥ 70 years, BMI < 20 kg/m2 is sometimes considered underweight. Loss of body weight is assessed based on the length of time over which weight has been lost. In addition to the standards listed in the table, people with ≥ 5% loss of body weight within 6 months or ≥ 10% loss of body weight in ≥ 6 months are also considered suitable for nutrition assessment. Triceps skin fold (%TSF) and upper arm circumference (%AMC) are assessed in relation to reference values by sex and age classification shown in Japanese Anthropometric Reference Data 2001. Men and women with a calf circumference < 30 cm and < 29 cm, respectively, are also sometimes considered suitable for nutrition assessment.
Explanation
The risks of potential malnutrition and future malnutrition can be assessed based on items related to energy intake, such as appetite, digestive symptoms (diarrhea, vomiting, etc), feeding methods, dietary intake, and dysphagia as well as items related to energy consumption, such as physical activity and inflammatory diseases. Based on the characteristics of individual patients, we combine the endpoints related to energy intake and the endpoints related to energy consumption to assess both.
Explanation
There are many standardized tools for nutrition assessment, so assessors should choose a tool that is easy for them to use based on the age and number of the patients to be assessed. Other tools for nutrition assessment include Controlling Nutrional Status (CONUT) and the Geriatric Nutritional Risk Index (GNRI), both of which use blood biochemistry values.
CONUT converts serum albumin concentration, total peripheral lymphocyte count, and total cholesterol concentration into scores to produce an aggregate score that serves as an indicator for assessing nutrition. At medical institutions, when blood biochemistry data is usable, it serves as a useful objective indicator.
The GNRI, which was made for elderly people, is calculated based on serum albumin concentration, body weight, and standard body weight. The GNRI is also known to indicate the risk of complications associated with malnutrition, such as aspiration pneumonia and pressure ulcers.
Explanation
The Subjective Global Assessment (SGA), which is widely used in Japan, comprises items related to patient records (medical history) and physical symptoms. Based on the results, patients are classified as nourished, mildly malnourished, or severely malnourished. The SGA is valid for a wide range of ages, is simple, is highly reproducible, and correlates highly with other indices of nutrition. In the West, the SGA has been adopted in various guidelines. While the subjective nature of SGA can easily result in variation among assessors, this variation can be reduced with training.
Explanation
Patients classified by the SGA as mildly or severely malnourished are suitable for nutrition assessment.
Explanation
For children, keep in mind that the assessment criteria for physical measurements and blood biochemistry values are different from the criteria used for adults.
The Kaup index is used in place of BMI as a method for assessing physical measurements. As with BMI, anyone who doesn't meet the standard for their age classification is considered suitable for nutrition assessment. Continuous assessments throughout childhood also often employ BMI percentiles and BMI standard deviation scores. Assessments for children are based on standard BMI by age, as shown on the Japanese Society for Pediatric Endocrinology's website (http://jspe.umin.jp/medical/taikaku.html). Children below the 3% percentile are considered suitable for nutrition assessment; however, cutoff values should be examined on a case-by-case basis.
Explanation
Nutrition assessment involves evaluating the specific nature and degree of malnutrition (or the risk of malnutrition) in patients identified in nutrition screening and determining the cause of their malnutrition. Here, we integrate multiple pieces of information to accurately grasp the nutritional status and disease state and to make a comprehensive assessment. Also, gathering information on underlying environmental factors and mental state helps greatly with planning future nutritional care.
Explanation
People whose energy and nutrient intakes may be below physiologically required levels exhibit the signs shown in the table. In blood biochemistry tests, transthyretin (TTR) and albumin (alb) are both indicators of visceral protein levels; however, changes in nutritional status can be grasped more keenly with TTR than with alb thanks to the former's short half-life (1.9 days versus 21 days, respectively). When C-reactive protein (CRP) or body temperature is elevated, energy consumption associated with inflammatory response increases, which can easily lead to a relative deficiency in energy. However, CRP is a protein and isn't always elevated in undernutrition.
Explanation
A dysphagia diet, which consists of normal food with its thickness modified by the addition of water, often doesn't contain sufficient energy or nutrients. For patients on a dysphagia diet, we need to assess not only their dietary intake, but also their nutritional intake.
Explanation
Patients with dysphagia are prone to dehydration. This is especially true of patients who require water to be thickened, which reduces their water intake. In blood biochemistry tests and urine tests, highly concentrated blood or urine indicates dehydration. Other signs of dehydration include dry skin, dry mucous membranes, and reduced skin tone.
References
- Yamamoto T:Nutritional Screening and Inquiry, The Japan Dietetic Association Eds:Nutritional Management Process, Daiichi Shuppan, Tokyo, 2018, 16-23.
- Japanese Society of Nutritional Assessmnt Anthropometric Standard Value Review Committee:New standard value of Japanese height: JARD 2001, Nutrition-Evaluation and Treatmnet, 2002, 19(suppl):1-81, 2002.
- Detsky AS, McLaughlin JR, Baker JP, et al: What is subjective global assessment of nutritional status?, JPEN, 11:8-13, 1987.
- Hayakawa M, Nishimura K, Yamada T et al:Effective usage of Nutritional Assessment Tool, J JSPEN, 25:13-16, 2010.
- Takaya R、Niekawa T:Body measurement・Physical examination, Japanese Society for Pediatric Gastroenterology and Nutrition Ed, Shoni Rinsho Eiyogaku 2nd ed, Shindan to Chiryosha, Tokyo, 2018, 96-101.
- Ishinaga K:Nutritional evaluation data, The Japan Dietetic Association Eds:Nutritional Management Process, Daiichi Shuppan, Tokyo, 2018, 26-27.
