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Patients unable to take sufficient food and dietary supplements to meet their nutritional requirements should be considered for an enteral tube feed.

Patients unable to eat at all should have an enteral tube feed. Reasons for complete inability to eat include carcinoma of the head and neck area or oesophagus, surgery to the head or oesophagus, radiotherapy treatment to the head or neck and fistulae of the oral cavity or oesophagus.

Parenteral nutrition (PN) may be indicated in patients with a non-functioning or inaccessible gastrointestinal (GI) tract who are likely to be ‘nil by mouth’ for 5 days or longer. Reasons for a non-functioning or inaccessible GI tract include bowel obstruction, short bowel syndrome, gut toxicity following bone marrow transplantation or chemotherapy, major abdominal surgery, uncontrolled vomiting and enterocutaneous fistulae. Enteral nutrition should always be the first option when considering nutritional support.

Patients in any group may have an increased requirement for nutrients due to an increased metabolic rate, as found in those with burns, major sepsis, trauma or cancer cachexia (Bozzetti 2001, Thomas 2007, Todorovic and Micklewright 2004). Patients should have nutritional requirements estimated prior to the start of nutritional support and should be monitored regularly.

Methods of assessing of nutritional status

Before the initiation of nutritional support, the patient must be assessed. The purpose of assessment is to identify whether a patient is undernourished, the reasons why this may have occurred and to provide baseline data for planning and evaluating nutritional support (NCCAC 2006). It is helpful to use more than one method of assessing nutritional status. For example, a dietary history may be used to assess the adequacy of a person’s diet but does not reflect actual nutritional status, whereas percentage weight loss does give an indication of nutritional status. However, percentage weight loss taken in isolation gives no idea of dietary intake and likelihood of improvement or deterioration in nutritional status (NCCAC 2006).

Bodyweight and weight loss

Body Mass Index (BMI) or comparison of a patient’s weight with a chart of ideal bodyweight gives a measure of whether the patient has a normal weight, is overweight or underweight, and may be calculated from weight and height using the following equation:

Tables are available to allow the rapid and easy calculation of BMI (BAPEN 2003a). These comparisons, however, are not a good indicator of whether the patient is at risk nutritionally, as an apparently normal weight can mask severe muscle wasting.

Of greater use is the comparison of current weight with the patient’s usual weight. Percentage weight loss is a useful measure of the risk of malnutrition:

A patient would be identified as malnourished if they had any of the following:

BMI less than 18.5 kg/m2

unintentional weight loss greater than 10% within the last 3–6 months

BMI less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.

(NCCAC 2006)

Sick children should have their weight and height measured frequently. It may be useful to measure on a daily basis (Shaw and Lawson 2007). These measurements must be plotted onto centile charts. A single weight or height cannot be interpreted as there is much variation of growth within each age group. It is a matter of concern if a child’s weight begins to fall across the centiles or if the weight plateaus.

Obesity and oedema may make interpretation of bodyweight difficult; both may mask loss of lean body mass and potential malnutrition (Pennington 1997).

Accurate weighing scales are necessary for measurement of bodyweight. Patients who are unable to stand may require sitting scales.

It is often not appropriate to weigh palliative care patients who may experience inevitable weight loss as disease progresses. Psychologically, it may be difficult for patients to see that they are continuing to lose weight. Measures