**3. Nutritional pharmacology**

**Figure 2.** Nutritional assessment

**1.** *Food intake*

124 Seminars in Dysphagia

**2.** *Body weight*

**3.** *Physical examination*

weight (18.5–24.9 kg/m2

II obesity (35.0–39.9 kg/m2

The nutritional history should evaluate the following:

A change in the dietary pattern due to dysphagia should be ascertained.

*stress* due to accompanied illness or injury also need to be ascertained.

*Body mass index (BMI)*: Patients are classified by BMI as underweight (<18.5 kg/m2

), or class III obesity (≥40.0 kg/m<sup>2</sup>

*Hand grip strength, gait speed, triceps skin fold thickness, mid-arm circumference, mucosal xerosis,* and *edema* are some of the physical signs which could help establish malnutrition in patients with dysphagia. Handgrip strength reflects, in part, the association of muscle strength and lean body mass with malnutrition [22]. In a study conducted by the International Academy on

), overweight (25.0–29.9 kg/m2

), normal

), class

), class I obesity (30.0–34.9 kg/m2

) [21].

The presence of unintentional weight loss over past six months should be ascertained. 10% or greater unintentional weight loss over the past six months is categorised as severe weight loss and is associated with a poor clinical outcome. In a study involving 3,047 patients enrolled in 12 chemotherapy protocols of Eastern Cooperative Oncology Group, Dewys WD, et al. has shown that chemotherapy response rates and median survival rates were lower in patients with weight loss [20]. The *functional status* of the patients (e.g., bedridden) and *metabolic*

If a patient is identified as at risk of malnutrition, appropriate intervention should be done to improve outcomes. Nutritional pharmacology is an emerging science over the last two decades. Nutrients such as arginine, glutamine, and long chain fatty acids (both omega 3 and omega 6) have been shown to improve clinical outcomes in diverse group of patients [28]. Arginine exhibits diverse effects including wound healing, protects against ischemia-reper‐ fusion, improves macrophage function after injury, blocks adhesion molecules, inhibits lipid peroxidation, and improves cerebral and myocardial perfusion [28]. In a double blind randomised controlled trial involving 32 malnourished patients with head and neck cancer, Buijs N et al. concluded that perioperative arginine-enriched enteral nutrition improved long term overall survival and long term disease specific survival [29]. Glutamine is the most abundant amino acid and is a fuel of neutrophils, lymphocytes, and enterocytes. Glutamine is a conditionally essential amino acid in situations of stress. A recent Cochrane review including 4,671 patients with critical illness or elective major surgery concluded that glutamine supple‐ mentation reduced the infection rate and days on mechanical ventilation in critically ill or surgical patients [30]. Long chain fatty acids are important in function of cell membranes and act as intracellular messengers.
