Malnutrition - ACDIS

MalnutritionBy 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 ulcerdevelopment The annual burden of disease-associated malnutrition across 8 diseases in theU.S. is 156.7 billion

What is malnutrition?“An acute, subacute or chronic state of nutrition in which a combination of varyingdegrees of overnutrition or undernutrition with or without inflammatory activityhave 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 monthsBody mass index less than 18.5 kg/m2 or greater than 25 kg/m2Chronic diseaseIncreased metabolic requirementsModified DietInadequate nutrition intake, including not receiving food or nutrition products forgreater than 7 days

Malnutrition Diagnoses Involves: Knowledge about the needs ofthe population and individualpatient Clinical judgement Evidence-based practice Nutrition standards

Malnutrition Etiologies Social/ Environmental Circumstances – Chronic starvation withoutinflammation (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, sarcopenicobesity) Acute Illness/ Injury - Moderate – severe inflammation for less than 3 months(ex. infection, burns, trauma or pancreatitis, major surgery)

Diagnosis CriteriaWeight loss: considers hydration status; weight change over time is represented as a percentageof weight loss from baselineIntake: RD obtains diet history and estimates energy needs; inadequate intake is represented as apercentage of estimated need over timePhysical 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, orvulvar/scrotal edema)Functional Assessment: based on standards supplied by manufacturer of dynamometer

Diagnosis CriteriaWeight 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 monthsIntake 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 ExamBIDMC approved abbreviation: NFPEx A head to toe examination to determine micronutrient deficiencies and fat, muscleloss

Diagnosis CriteriaLoss of subcutaneous fat Orbital, triceps, thoracic, lumbar, ribs, midaxillary lineLoss of lean muscle Temporalis muscle, clavicular and acromion bone, deltoid muscle, interosseous muscle, anteriorthigh, quadriceps, patellar region, gastrocnemius

Diagnosis criteriaEdema & 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 wastingNFPExPatellar and Quadricep muscle wasting

Things to look out for in nutrition notes NFPExAssessment:Muscle lossAdequately nourished, obese, malnourished(mild/moderate/severe)Fat lossSkinHead/hairModerate-severe temporalwasting, somewhatprominent iliac crest,protruding acromionprocess,angular r Extremity 50%of usualintake x7 daysVersusN/V x 3daysPatient at risk of malnutrition due to: poor pointake, NPO/ hypocaloric intake, otherEstimated Daily needs of kcal, protein, fluidEstimation of current/previous intake

Malnutritiondefinitions Diagnosis of adult malnutritionshould be based on two or more ofthe criteriaCriteria apply at ALL BMI levelsICD-10 Code: E43Severe MalnutritionSevere Malnutrition inContext of Acute Illness /Injury ( 3 months)Severe Malnutrition inContext of Chronic Illness( 3 months)Severe Malnutrition in Context ofSocial / Behavioral / EnvironmentalCircumstancesWeight Loss – is evaluated in light ofother clinical findings including hydration.Weight change over time is reported aspercentage of weight loss from baseline.Weight Loss 2% in 1 week 5% in 1 month 7.5% in 3 monthsWeight Loss 5% in 1 month 7.5% in 3 months 10% in 6 months 20% in 12 monthsWeight Loss 5% in 1month 7.5% in 3 months 10% in 6 months 20% in 12 monthsIntake – R.D. obtains diet history andestimates energy needs. Suboptimalintake is determined as a percentage ofestimated need over time.Energy Intake 50% energy intakecompared to estimatedenergy needs for 5 daysEnergy Intake 75% energy intakecompared to estimatedenergy needs for 1 monthEnergy Intake 50% energy intake compared toestimated energy needs for 1 monthPhysical Assessment – loss ofsubcutaneous fat (i.e. orbital, triceps, fatoverlying ribcage)Body FatModerate depletionBody FatSevere depletionBody FatSevere depletionPhysical Assessment – loss of muscle(i.e. temples, clavicles, shoulders,scapula, thigh and calf)Muscle MassModerate depletionMuscle MassSevere depletionMuscle MassSevere depletionPhysical Assessment - general or localfluid accumulation (i.e. extremities, ascitesor vulvar / scrotal edema)Fluid AccumulationModerate to SevereFluid AccumulationSevereFluid AccumulationSevereFunctional Assessment – based onstandards supplied by manufacturer ofdynamometerReduced Grip StrengthNot recommended in IntensiveCare SettingReduced Grip StrengthMeasurably reduced for ageand genderReduced Grip StrengthMeasurably reduced for age andgenderICD-10 Code: E44.0Moderate MalnutritionNon-Severe Malnutrition inContext of Acute Illness /Injury ( 3 months)Non-Severe Malnutrition inContext of Chronic Illness( 3 months)Non-Severe Malnutrition inContext of Social / Behavioral /Environmental CircumstancesWeight Loss – is evaluated in light ofother clinical findings including hydration.Weight change over time is reported aspercentage of weight loss from baseline.Weight Loss1 to 2% in 1 week5% in 1 month7.5% in 3 monthsWeight Loss5% in 1month7.5% in 3 months10% in 6 months20% in 12 monthsWeight Loss5% in 1 month7.5% in 3 months10% in 6 months20% in 12 monthsIntake – R.D. obtains diet history andestimates energy needs. Suboptimalintake is determined as a percentage ofestimated need over time.Energy Intake 75% energy intakecompared to estimatedenergy needs for 7 daysEnergy Intake 75% energy intakecompared to estimatedenergy needs for 1 monthEnergy Intake 75% energy intake compared toestimated energy needs for 3 monthsPhysical Assessment – loss ofsubcutaneous fat (i.e. orbital, triceps, fatoverlying ribcage)Body FatMild depletionBody FatMild depletionBody FatMild depletionPhysical Assessment – loss of muscle(i.e. temples, clavicles, shoulders,scapula, thigh and calf)Muscle MassMild depletionMuscle MassMild depletionMuscle MassMild depletionPhysical Assessment – general or localfluid accumulation (i.e. extremities, ascitesor vulvar / scrotal edema)Fluid AccumulationMildFluid AccumulationMildFluid AccumulationMildFunctional Assessment – based onstandards supplied by manufacturer ofdynamometerReduced Grip StrengthNot applicableReduced Grip StrengthNot applicableReduced Grip StrengthNot applicable

Case Study J.M.72YO F who reports 6-7 months of decreased appetite r/t nausea. Consuming smaller breakfast, skipping L/Dsome days or having small bowl of soup, ½ sandwich.59 in, Admit weight: 57 kg, UBW 70-72 kgDx: Pancreatic cyst (polycystic intraductal papillary mucinous neoplasia of the pancreasPMhx: PE x 2, GERD, thyroid CA, anemia, pancreatitisLabs: glucose 197 mg/dL, all other labs WNLDiet order: NPONo physical assessment performedAbdomen 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% energyintake 1 month r/t nausea Plan for diet advancement to low fat, starting diabetic oral supplements andtrending weights

When Should You Contact a Dietitian?When a patient is suspected to have moderate or severe malnutritionTo confirm a diagnosis by verifying that at least 2 criteria have been metTo rule out other possible conditions

WRAP UP No universal definition of malnutrition Diagnosis requires anthropometric data, food/nutrient intake, laboratory data and acomplete NFPEx completed by an RD Malnutrition is associated with increased hospital costs, 1.5-5x higher rate of inhospital death, 4x higher risk of developing pressure ulcer, and 2x longer hospitalstays

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