Malnutrition By Litsa Georgakilas, RD LDN CNSC Overview How is malnutrition defined? Malnutrition diagnosis ASPEN guidelines Contacting a dietitian Malnutrition: Did you know... • 1 in 3 patients are malnourished on admission • Patients diagnosed with malnutrition have a 3 times longer LOS • Surgical patients with malnutrition have a 4 times higher risk of pressure ulcer development • The annual burden of disease-associated malnutrition across 8 diseases in the U.S. is $156.7 billion What is malnutrition? “An acute, subacute or chronic state of nutrition in which a combination of varying degrees of overnutrition or undernutrition with or without inflammatory activity have led to a change in body composition and diminished function.” – American Society of Parenteral Enteral Nutrition Who is at risk? Adults should be considered at risk if they have any of the following: • Involuntary loss or gain within 6 months • Body mass index less than 18.5 kg/m2 or greater than 25 kg/m2 • Chronic disease • Increased metabolic requirements • Modified Diet • Inadequate nutrition intake, including not receiving food or nutrition products for greater than 7 days Malnutrition Diagnoses ● Involves: ○ Knowledge about the needs of the population and individual patient ○ Clinical judgement ○ Evidence-based practice ○ Nutrition standards Malnutrition Etiologies • Social/ Environmental Circumstances – Chronic starvation without inflammation (access to food is limited, ex. Anorexia nervosa, physical conditions) • Chronic Illness – mild- moderate inflammation for 3 months or longer (ex. cancer, AIDS, COPD, celiac disease, CF, DM, chronic pancreatitis, sarcopenic obesity) • Acute Illness/ Injury - Moderate – severe inflammation for less than 3 months (ex. infection, burns, trauma or pancreatitis, major surgery) Diagnosis Criteria Weight loss: considers hydration status; weight change over time is represented as a percentage of weight loss from baseline Intake: RD obtains diet history and estimates energy needs; inadequate intake is represented as a percentage of estimated need over time Physical Assessment (FAT): loss of subcutaneous fat (i.e. triceps, fat overlying ribcage) Physical Assessment (MUSCLE): loss of muscle (i.e. clavicles, shoulders, thigh) Physical Assessment (FLUID): general or local fluid accumulation (i.e. extremities, ascites, or vulvar/scrotal edema) Functional Assessment: based on standards supplied by manufacturer of dynamometer Diagnosis Criteria Weight loss • Acute Illness- weight change estimated over 1 week, 1 month or 3 months • Chronic Illness- weight change estimated over 1 month, 3 months, 6 months, 12 months Intake • Severe- Acute- </= 50% of estimated needs >/= 5 days • Moderate- Acute- <75% of estimated needs > 7 days • Severe- Chronic- </= 75% of estimated needs >/= 1 month • Moderate- Severe- <75% of estimated needs >/= 1 month Nutrition Focused Physical Exam BIDMC approved abbreviation: NFPEx • A head to toe examination to determine micronutrient deficiencies and fat, muscle loss Diagnosis Criteria Loss of subcutaneous fat • Orbital, triceps, thoracic, lumbar, ribs, midaxillary line Loss of lean muscle • Temporalis muscle, clavicular and acromion bone, deltoid muscle, interosseous muscle, anterior thigh, quadriceps, patellar region, gastrocnemius Diagnosis criteria Edema & Ascites • Weight loss may be masked by fluid retention • Used as supportive evidence, but not necessarily r/t malnutrition • Localized vs Generalized • Scale +1 to +4 Mild: +1 (2mm) Moderate: +2 (2-4mm) Severe: +3 or greater (4-8mm) Interossous muscle wasting NFPEx Patellar and Quadricep muscle wasting Things to look out for in nutrition notes… NFPEx Assessment: Muscle loss Adequately nourished, obese, malnourished Fat loss Moderate-severe temporal (mild/moderate/severe) wasting, somewhat N/V x 3 prominent iliac crest, Skin Versus protruding acromion days process, Head/hair angular stomatitis Patient at risk of malnutrition due to: poor po intake, NPO/ hypocaloric intake, other Eyes/Nose/Mouth Hands/Nails <50% Estimated Daily needs of kcal, protein, fluid of usual GI/Abdomen intake x Estimation of current/previous intake 7 days Lower Extremity Severe Malnutrition in Severe Malnutrition in Severe Malnutrition in Context of ICD-10 Code: E43 Context of Acute Illness / Context of Chronic Illness Social / Behavioral / Environmental Severe Malnutrition Injury (<3 months) (>3 months) Circumstances Weight Loss Weight Loss Weight Loss Weight Loss – is evaluated in light of > 2% in 1 week > 5% in 1 month > 5% in 1month other clinical findings including hydration. > 7.5% in 3 months > 7.5% in 3 months Weight change over time is reported as > 5% in 1 month percentage of weight loss from baseline. > 7.5% in 3 months > 10% in 6 months > 10% in 6 months > 20% in 12 months > 20% in 12 months Malnutrition Intake – R.D. obtains diet history and Energy Intake Energy Intake Energy Intake estimates energy needs. Suboptimal ≤ 50% energy intake ≤ 75% energy intake ≤ 50% energy intake compared to intake is determined as a percentage of compared to estimated compared to estimated estimated energy needs for ≥ 1 month estimated need over time. energy needs for ≥ 5 days energy needs for ≥ 1 month Physical Assessment – loss of Body Fat Body Fat Body Fat subcutaneous fat (i.e. orbital, triceps, fat Moderate depletion Severe depletion Severe depletion overlying ribcage) definitions Physical Assessment – loss of muscle Muscle Mass Muscle Mass Muscle Mass (i.e. temples, clavicles, shoulders, Moderate depletion Severe depletion Severe depletion scapula, thigh and calf) Physical Assessment - general or local Fluid Accumulation Fluid Accumulation Fluid Accumulation fluid accumulation (i.e. extremities, ascites Moderate to Severe Severe Severe or vulvar / scrotal edema) Functional Assessment – based on Reduced Grip Strength Reduced Grip Strength Reduced Grip Strength • Diagnosis of adult malnutrition standards supplied by manufacturer of Not recommended in Intensive Measurably reduced for age Measurably reduced for age and dynamometer Care Setting and gender gender Non-Severe Malnutrition in Non-Severe Malnutrition in Non-Severe Malnutrition in ICD-10 Code: E44.0 should be based on two or more of Context of Acute Illness / Context of Chronic Illness Context of Social / Behavioral / Moderate Malnutrition Injury (< 3 months) (> 3 months) Environmental Circumstances Weight Loss Weight Loss Weight Loss Weight Loss – is evaluated in light of the criteria 1 to 2% in 1 week 5% in 1month 5% in 1 month other clinical findings including hydration. 7.5% in 3 months 7.5% in 3 months Weight change over time is reported as 5% in 1 month percentage of weight loss from baseline. 7.5% in 3 months 10% in 6 months 10% in 6 months 20% in 12 months 20% in 12 months Intake – R.D. obtains diet history and Energy Intake Energy Intake Energy Intake estimates energy needs. Suboptimal < 75% energy intake < 75% energy intake < 75% energy intake compared to • Criteria apply at ALL BMI levels intake is determined as a percentage of compared to estimated compared to estimated estimated energy needs for estimated need over time. energy needs for > 7 days energy needs for ≥ 1 month ≥ 3 months Physical Assessment – loss of Body Fat Body Fat Body Fat subcutaneous fat (i.e. orbital, triceps, fat Mild depletion Mild depletion Mild depletion overlying ribcage) Physical Assessment – loss of muscle Muscle Mass Muscle Mass Muscle Mass (i.e. temples, clavicles, shoulders, Mild depletion Mild depletion Mild depletion scapula, thigh and calf) Physical Assessment – general or local Fluid Accumulation Fluid Accumulation Fluid Accumulation fluid accumulation (i.e. extremities, ascites Mild Mild Mild or vulvar / scrotal edema) Functional Assessment – based on Reduced Grip Strength Reduced Grip Strength Reduced Grip Strength standards supplied by manufacturer of Not applicable Not applicable Not applicable dynamometer Case Study J.M. 72YO F who reports 6-7 months of decreased appetite r/t nausea. Consuming smaller breakfast, skipping L/D some days or having small bowl of soup, ½ sandwich. 59 in, Admit weight: 57 kg, UBW 70-72 kg Dx: Pancreatic cyst (polycystic intraductal papillary mucinous neoplasia of the pancreas PMhx: PE x 2, GERD, thyroid CA, anemia, pancreatitis Labs: glucose 197 mg/dL, all other labs WNL Diet order: NPO No physical assessment performed Abdomen WNL, NGT with no output Coding • Patient was seen POD1 from subtotal pancreatectomy and splenectomy • Chronic -Severe malnutrition: 30 lb (19%) weight loss x 6- 7 months , <75% energy intake >1 month r/t nausea • Plan for diet advancement to low fat, starting diabetic oral supplements and trending weights When Should You Contact a Dietitian? When a patient is suspected to have moderate or severe malnutrition To confirm a diagnosis by verifying that at least 2 criteria have been met To rule out other possible conditions WRAP UP • No universal definition of malnutrition • Diagnosis requires anthropometric data, food/nutrient intake, laboratory data and a complete NFPEx completed by an RD • Malnutrition is associated with increased hospital costs, 1.5-5x higher rate of in hospital death, 4x higher risk of developing pressure ulcer, and 2x longer hospital stays References http://journals.sagepub.com/doi/pdf/10.1177/0148607113512154 https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=11&lv1=144942&lv2=272214&ncm_toc_id=272214&ncm_headin g=& https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=11&lv1=144942&lv2=272215&ncm_toc_id=272215&ncm_headin g=& http://www.nutritioncare.org/malnutrition/ http://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Toolkits/Malnutrition_Toolkit/ http://www.nutritioncare.org/uploadedImages/01_Site_Directory/Graphics_Directory/MAW/ASPEN%20Adult%20Care%20pathway_ Page_1.jpg?n=265 file:///C:/Users/Ashley%20St.%20Amand/Downloads/AMN%20FAQs%20November%202014_Final.pdf .