Stability of body weight requires that energy intake and expenditures are balanced over time. The major categories of energy output are resting energy expenditure (REE) and physical activity; minor sources include the energy cost of metabolizing food (thermic effect of food or specific dynamic action) and shivering thermogenesis. The average energy intake is about 2600 kcal/d for men and about 1800 kcal/d for women, though these estimates vary with age, body size, and activity level. Malnutrition occurs in 30–50% of hospitalized pts, depending upon the setting and severity of illness. The presence of inflammation, including after surgical procedures, can increase energy expenditure and alter nutritional assessment indicators such as albumin.
Dietary reference intakes (DRIs) and recommended dietary allowances (RDAs) have been defined for many nutrients, including 9 essential amino acids, 4 fat-soluble and 10 water-soluble vitamins, several minerals, fatty acids, choline, and water (see Tables 325-1, 325-2, and 325-3 in HPIM-20). The usual water requirements are 1.0–1.5 mL/kcal energy expenditure in adults, with adjustments for excessive losses. The RDA for protein is 0.6-g/kg ideal body weight, representing 10–15% of total caloric intake. Fat should constitute ≤30% of calories, and saturated fat should be <10% of calories. At least 55% of calories should be derived from carbohydrates.
Malnutrition results from inadequate intake or abnormal GI assimilation of dietary calories, excessive energy expenditure, or altered metabolism of energy supplies by an intrinsic disease process.
Both outpatients and inpatients are at risk for malnutrition if they meet one or more of the following criteria:
Unintentional loss of >10% of usual body weight in the preceding 3 months
Body weight <90% of ideal for height
Body mass index (BMI: weight/height2 in kg/m2) <18.5
The major etiologies of malnutrition are starvation, stress from surgery or severe illness, and mixed mechanisms. Starvation results from decreased dietary intake (from poverty, chronic alcoholism, anorexia nervosa, fad diets, severe depression, neurodegenerative disorders, dementia, or strict vegetarianism; abdominal pain from intestinal ischemia or pancreatitis; or anorexia associated with AIDS, disseminated cancer, heart failure, or renal failure) or decreased assimilation of the diet (from pancreatic insufficiency; short bowel syndrome; celiac disease; or esophageal, gastric, or intestinal obstruction). Contributors to physical stress include fever, acute trauma, major surgery, burns, acute sepsis, hyperthyroidism, and inflammation as occurs in pancreatitis, collagen vascular diseases, and chronic infectious diseases such as tuberculosis or AIDS opportunistic infections. Mixed mechanisms occur in AIDS, disseminated cancer, chronic obstructive pulmonary disease, chronic liver disease, Crohn’s disease, ulcerative colitis, and renal failure.
The historical features, clinical signs, and laboratory indicators of potential malnutrition are summarized in Tables 7-1 and 7-2.
TABLE 7-1History and Physical Examination Elements