2. Nutrition SUBJECTIVE FINDINGS  1 month prior to consult, patient claimed to have lost 20-30% of her weight (can be classified as severe weight loss), anorexic  Markedly decreased oral intake (short starvation) due to vomiting after each oral intake  Patient lived on water, coffee, and diluted Bear Brand (intolerance of both solid and soft diet becoming almost daily)  Weak, able to stand up with support and poor hand grip  Evidence of muscle wasting

3. Nutrition OBJECTIVE FINDINGS  Weight is 35 kg; height is 1.5m; BMI (kg/m2) is 15.6. Based on the Asia-Pacific BMI classification, the patient is underweight. Normal BMI= 18.5-22.9  Severe weight loss (>5-10%)  Ideal body weight computation = 45kg  Patient is less than 10 kg of his Ideal Body weight  %IBW= 35kg/45kg = 78%, meaning that current weight is 78% of ideal body weight, patient is classified under moderate malnutrition

4. Nutrition ASSESSMENT  ABC’s of Nutritional Assessment 1. Anthropometric Measurements (Height, Weight, BMI, Triceps Skin Fold, Mid-Arm Circumference, Mid Arm Mass Circumference) BMI=15.6 (Underweight); IBW (Tanhausser’s)= 45kg; %IBW= 78%- moderate malnutrition %wt loss= severe (>5% in 1 month) 2. Biochemical Parameters (Common: Serum albumin <3.0g%; Total Lymphocyte <1500) 3. Clinical Parameters or Manifestations (Nutritional Risk Screening, 2002, First and Second Screening) Impaired Nutritional Status= Wt loss >5% in 1 mos or >15% in 3 mos, or BMI <18.5 + impaired general condition or food intake

5. PLAN  Appropriate nutritional assessment.  Institute a nutritional care plan for the patient. (Patient is nutritionally at- risk, NRS score of >=3)  Calculate for total energy allowance and protein, carbohydrates, and fats requirement  Method of delivery: IV route then oral upon improvement (Pt has been vomiting, pt has poor hand grip)

6. Nutrition: NRS, 2002 ESPEN Guideline Table 1 Initial Screening Yes No 1Is BMI<20.5 2Has the patient lost weight within the last 3 months? 3Has the patient had a reduced dietary intake in the last week 4Is the patient severely ill? (e.g intensive therapy) Yes: If the answer is “Yes” to any of the question, the screening in Table 2 is performed. No: If the answer is “No” to all questions, the patient is re-screened at weekly intervals. If the patient e.g is schedules for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status.

7. Nutrition: NRS, 2002 ESPEN Guideline Table 2 Final Screening Impaired Nutritional Status Severity of disease (increase in requirements) Absent Score 0 Normal nutritional StatusAbsent Score 0Normal nutritional requirements Mild Score 1 Wt loss >5% in 3 mos or Food intake below 50-75% of normal requirement in preceding week Mild Score 1Hip fracture, Chronic patients in particular with acute complications: cirrhosis, COPD, chronic hemodialysis, diabetes, oncology Moderate Score 2 Wt loss >5% in 2 mos or BMI 18.5- 20.5+ impaired general condition or food intake 25-60% of normal requirement in preceding week Moderate Score 2Major abdominal surgery, Stroke, Severe Pneumonia, hematologic malignancy Severe Score 3 Wt loss >5% in 1 mo or BMI <18.5 +impaired general condition or food intake 0-25% of normal requirement in preceding week Severe Score 3Head injury, Bone marrow transplantation, Intensive care patients (APACHE >10) Score + Total Score Age If >=70 years old, add 1 to total score = age adjusted total score Score >=3: the patient is nutritionally at risk and a nutritional care plan is initiated Score <3: weekly re-screening of the patient. If the patient e.g is schedules for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status.

8. Nutrition Calculating total energy allowance and protein, carbohydrates, and fats requirement Total energy allowance = Weight (kg) x Caloric requirement Total energy allowance = 35 x 45(kcal/kg/d) = 1575 kcal Protein ( 1.0 – 1.5 g/kg/d) = (35 x 1.5) x 4; Protein = 210 kcal Carbs= [(Total energy allowance – Calories from protein) x 0.7] / 4 Carbs = (1575 – 210) x (0.7) = 955 / 4 = 239 g CHO Fats (30-40% of non-CHON calories) = [(Total energy allowance – Calories from protein) x 0.3] / 9 Fats = (1575 – 210) x (0.3) = 409.5 / 9 = 45.5 g Fats Rapid Estimation of adult total daily calorie and protein requirement Severity of Illness Caloric Require ment (kcal/kg/ d) Protein Requireme nt (g/kg/d) None250.8 Mild to Moderate 351.0 Moderate to Severe 451.5

9. Nutrition Monitoring: Laboratory parameters, Body weight improvement, Functional status Laboratory parameters (serum albumin, lymphocyte, cholesterol, transferrin, iron-binding capacity)

10. General goal: Restore the patient’s nutritional, metabolic and functional status. Specific goals: 1. Provide the needed total caloric need to the patient following the macronutrient requirements of protein 15-20%, fats-30-35%, carbohydrates 50-60% of total calories. 2. Prevent complications of electrolyte and metabolic derangement that could lead to potentially life-threatening situations. 3. Prevent further complications of malnutrition such as muscle wasting Surgical operation –Relief from obstructive symptoms –Prevention of malabsorption caused by ileocecal TB –Nutritional delivery must prepare the patient for the surgical operation (monitoring of serum albumin) –VitB12 supplementation given post-surgery (since Vit B12 absorption is impaired in the terminal ileum)