IM24.1-5 | Nutrition Assessment and Support — Summary & Reflection

KEY TAKEAWAYS

Nutritional assessment uses the ABCD framework: Anthropometric (BMI, MUAC, skinfold, grip strength), Biochemical (albumin — chronic marker but acute-phase reactant; prealbumin — short half-life, better for monitoring response; nitrogen balance; specific vitamin levels), Clinical (deficiency signs by system), Dietary (caloric, protein, and micronutrient intake). MUST or NRS-2002 screening on every admission.

PEM: Marasmus = global calorie + protein deprivation; severe wasting, normal albumin, no oedema. Kwashiorkor = protein deficiency; hypoalbuminaemia, oedema, 'flaky paint' dermatosis, hepatomegaly, flag sign in hair.

Key vitamin deficiency syndromes: Vitamin A — night blindness, Bitot spots, keratomalacia. Thiamine (B1) — dry beriberi (neuropathy), wet beriberi (high-output HF), Wernicke-Korsakoff (thiamine BEFORE glucose). Niacin (B3) — pellagra: the 4 Ds (dermatitis/Casal necklace, diarrhoea, dementia, death). B12 — megaloblastic anaemia + SACD (subacute combined degeneration — posterior and lateral cord); absent in folate deficiency. Vitamin C — scurvy: gum bleeding, perifollicular haemorrhage, impaired wound healing. Vitamin D — rickets (children), osteomalacia (adults), proximal myopathy.

Refeeding syndrome: hypophosphataemia + hypokalaemia + hypomagnesaemia + thiamine depletion on re-feeding after starvation. Start feeds at 5–10 kcal/kg/day; supplement PO₄, K, Mg; thiamine before feeding.

Artificial nutrition: If the gut works, use it. EN (NGT → PEG for >4 weeks) is preferred. PN only when gut cannot be used (short bowel, bowel obstruction, high-output fistula). Targets: 25–30 kcal/kg/day, 1.2–2.0 g/kg/day protein. Complications of PN: CRBSI, hyperglycaemia, TPN-cholestasis, refeeding syndrome.

REFLECT

Return to the patient from the opening scenario — the farmer with maize-dependent diet, wasting, oedematous ankles, and flaky skin. Applying the ABCD framework, what do you now know: his anthropometric findings (temporal wasting, ankle oedema) suggest protein deficiency (kwashiorkor component) alongside global calorie deficiency; the albumin of 2.1 g/dL confirms hypoalbuminaemia; the mixed peripheral blood film (macro + microcytes) suggests concurrent B12/folate deficiency and iron deficiency; the photosensitive dermatosis on sun-exposed areas and the diarrhoea-confusion syndrome point to pellagra from the maize-dominant diet. His inability to walk is likely a combination of proximal myopathy (protein deficiency + vitamin D deficiency), peripheral neuropathy (pellagra or thiamine), and possible SACD from B12 deficiency. A complex patient — but now tractable. What investigations would you order first, and in what sequence would you begin nutritional rehabilitation to avoid refeeding syndrome while addressing all identified deficiencies? The answer to that question — synthesising physiology, biochemistry, and clinical judgment — is precisely what competencies IM24.1 through IM24.5 require you to demonstrate.