Malnutrition By Litsa Georgakilas, RD LDN CNSC Overview

 How is malnutrition defined?

 Malnutrition diagnosis

 ASPEN guidelines

 Contacting a 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 development

• The annual burden of -associated malnutrition across 8 in the U.S. is $156.7 billion What is malnutrition?

“An acute, subacute or chronic state of in which a combination of varying degrees of 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 • less than 18.5 kg/m2 or greater than 25 kg/m2 • Chronic disease • Increased metabolic requirements • Modified • Inadequate nutrition intake, including not receiving 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 without inflammation (access to food is limited, ex. nervosa, physical conditions)

• Chronic Illness – mild- moderate inflammation for 3 months or longer (ex. cancer, AIDS, COPD, celiac disease, CF, DM, , sarcopenic )

• Acute Illness/ Injury - Moderate – severe inflammation for less than 3 months (ex. , burns, trauma or pancreatitis, major surgery)

Diagnosis Criteria

Weight loss: considers hydration status; weight change over time is represented as a percentage of 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 (): 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 )

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- /= 5 days

• Moderate- Acute- <75% of estimated needs > 7 days

• Severe- Chronic- /= 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 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 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 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 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 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, 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/ 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 , 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