65.Rehabilitation Nutrition

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Explanation

Rehabilitation nutrition is both "nutrition care management in consideration of rehabilitation" and "rehabilitation in consideration of nutrition" for disabled people and frail elderly people. It aims to improve nutritional status, sarcopenia, and frailty and to maximize functioning, activity, participation, and quality of life (QOL). We work toward these aims are based on the following: holistic assessment using the International Classification of Functioning, Disability, and Health (ICF); assessment of the presence and causes of malnutrition, sarcopenia, and excess/deficient nutrient intake; and diagnosis and goal setting for rehabilitation nutrition.

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Explanation

ICF is a tool used widely in rehabilitation around the world to systematically and holistically assess human health. ICF is divided into 3 categories: health condition; activity/functions/impairments; and contextual factors. Activity/function consists of mental functions, physical functions, body structures, activity, and participation. Contextual factors consist of personal factors and environmental factors. The category of mental functions/physical functions/body structures consists of mental and physical functions and structures at the biological level that occur as a result of health condition, disease, and drugs; examples include dysphagia, hemiplegia, and malnutrition. So, in dysphagia rehabilitation, malnutrition is an impairment, and nutrition assessment is a necessity.

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Explanation

Undernutrition is commonly observed in rehabilitation. Of all elderly patients admitted to acute care hospitals who also visit departments of rehabilitation due to hospital-associated deconditioning, 88% are undernourished. In addition, undernourished patients have low levels of independence in activities of daily living (ADL) upon discharge. This suggests that undernutrition is a factor in diminished ADL and that improving nutrition is crucial for improving ADL.

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Explanation

Patients admitted to recovery rehabilitation units after a stroke show high functional independence measure (FIM) efficiency (improvement in ADL) when their nutrition improves during hospitalization. Energy intake at admission also demonstrates an independent correlation with FIM efficiency. This suggests that improvement of nutrition and sufficient energy intake during hospitalization are important for improving ADL.

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Explanation

A new edition of the Rehabilitation Nutrition Treatment Guideline was published by the Japanese Association of Rehabilitation Nutrition in 2018. The Guideline comprises 4 diseases: cerebrovascular disease, proximal femoral fracture, adult cancer, and acute disease. For example, the following clinical question (CQ) and recommendation is listed for cerebrovascular disease.

[CQ]
Should enhanced nutritional therapy be given for elderly patients with cerebrovascular disease undergoing rehabilitation?
[Recommendation]
We weakly recommend enhanced nutrition care for older patients with cerebrovascular disease undergoing rehabilitation in acute phase to reduce mortality and infection, and to improve quality of life (evidence level: low; recommendation level: weak).

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Explanation

A management cycle called the rehabilitation nutrition care process is effective for high-quality rehabilitation nutrition. The rehabilitation nutrition care process comprises 5 stages: rehabilitation nutrition assessment/diagnostic reasoning, rehabilitation nutrition diagnosis, rehabilitation nutrition goal setting, rehabilitation nutrition intervention, and rehabilitation nutrition monitoring. Unlike conventional nutrition care management, the steps in rehabilitation nutrition diagnosis and of rehabilitation nutrition goal setting are explicitly defined.

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Explanation

Rehabilitation nutrition diagnosis of malnutrition involves diagnosing the risks of undernutrition, overnutrition, and malnutrition, as well as nutrient excess or deficiency. Undernutrition is caused by hunger (starvation), invasion (acute inflammation), and cachexia (chronic inflammation). . Overnutrition is the abnormal accumulation of fat caused by excess energy intake, insufficient energy consumption, and disease. Those at risk of undernutrition/overnutrition is defined as not currently being undernourished/overnourished but showing a high likelihood of future undernutrition/overnutrition. A state of insufficient nutrients, particularly reduced storage of nutrients in the body and the manifestation of deficiency symptoms associated with insufficiency, can be called a deficiency state. Overnutrition can be called a state of excess fat.

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Explanation

We can effectively diagnose undernutrition with the Global Leadership Initiative on Malnutrition (GLIM) criteria, which is expected to become widely used worldwide. First, based on a validated nutrition screening tool, people are judged to be at risk for undernutrition. Next, undernutrition is diagnosed if at least 1 of the following phenotypes and 1 of the following causes apply.

Phenotypes:

Body weight loss: > 5% in 6 months

Low BMI: < 18.5 (< 20 for persons aged ≥ 70 years)

Reduced muscle mass

Etiologies:

Reduced food intake/assimilation: ≤ 50% for ≥ 1 week

Inflammation: Acute or chronic inflammation

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Explanation

The sarcopenia component in rehabilitation nutrition diagnosis involves diagnosing the presence and cause of sarcopenia. If sarcopenia is diagnosed, as a next step we consider whether the biggest cause is age, (lack of) activity, (lack of) nutrition, or disease. This step also applies even in pre-sarcopenia involving only reduced muscle mass. Also, some patients with sarcopenia have only reduced muscle strength and/or reduced physical functioning without reduced muscle mass; in these patients as well, our next step is to consider whether the cause is age, (lack of) activity, (lack of) nutrition, or disease.

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Explanation

The malnutrition component of rehabilitation nutrition diagnosis involves diagnosing insufficient nutrient intake, excessive nutrient intake, risk of insufficient nutrient intake, and risk of excessive nutrient intake. Insufficient nutrient intake is defined as a nutrient intake which is currently less than the required amount (as determined by comparison with Dietary Reference Intakes for Japanese) regardless of whether nutrient insufficiency/deficiency or deficiency symptoms are present. Excessive nutrient intake is defined as current excessive intake, that is, overeating (as determined by comparison with Dietary Reference Intakes for Japanese), regardless of whether any nutrients are present in excess.

Risk of insufficient nutrient intake is defined as a state in which nutrient intake is not currently insufficient but is predicted to be insufficient in the future based on the person's medical situation and living environment regardless of whether nutrient insufficiency/deficiency or deficiency symptoms are present.

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Explanation

In rehabilitation nutrition goal setting, SMART goal setting is important. SMART is an acronym for specific, measurable, achievable, relevant, and time-bound. Goal setting in dysphagia rehabilitation and nutrition improvement cannot be regarded as SMART. SMART goal setting is important in both dysphagia and nutrition management.

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Explanation

Aggressive nutrition management aims to deliberately increase body weight and muscle mass. When body weight is reduced due to undernutrition and infection is either absent or only mild, nutrition can be improved if daily energy requirement = daily energy expenditure + daily energy accumulation (200-1000 kcal). Daily energy accumulation is determined by rehabilitation nutrition goal setting. Theoretically, with an energy balance of 7000-7500 kcal, the change in body weight would be ± 1 kg. So, as an example, if the goal of rehabilitation nutrition is to gain 1 kg body weight in 1 month, daily energy accumulation would be 250 kcal. Aggressive nutrition management requires simultaneous exercise therapy, particularly resistance training. In addition, hyperglycemia, steatosis, nephropathy, dyslipidemia, and electrolyte imbalance must be monitored. In sarcopenic dysphagia, aggressive nutrition management is important for improving swallowing function.

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Explanation

In conclusion, the perspective of rehabilitation nutrition can be summarized as follows. Undernutrition can cause dysphagia and restrict ADL. IIf dysphagia is caused by undernutrition, functional training will not sufficiently improve function without improving nutritional status. Doing functional training with patients who have poor nutrition management will not only exacerbate undernutrition and sarcopenia but can also exacerbate dysphagia. Treatment of dysphagia caused by undernutrition requires both nutrition improvement and functional training. Therefore, "there can be no rehabilitation without nutrition care" and "nutrition is a vital sign for rehabilitation".

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References

Wakabayashi H: Rehabilitation nutrition in general and family medicine. J Gen Fam Med, 18:153-154, 2017.
Wakabayashi H, Sashika H: Malnutrition is associated with poor rehabilitation outcome in elderly inpatients with hospital-associated deconditioning a prospective cohort study. J Rehabil Med, 46:277-282, 2014.
Nii M, Maeda K, Wakabayashi H, et al.: Nutritional Improvement and Energy Intake Are Associated with Functional Recovery in Patients after Cerebrovascular Disorders. J Stroke Cerebrovasc Dis, 25: 57-62, 2016.
Tanaka M、Kosaka S、Nishioka S et al.,:Clinical practice guideline of rehabilitation nutrition for adult cerebrovascular disease patients. JJARN 2: 260-267, 2018.
Cederholm T, Jensen GL, Correia MITD, et al.: GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community. Clin Nutr 2018 doi: 10.1016/j.clnu.2018.08.002.

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