Angela Karnes

RD, CNSC, LDN

To identify in the adult inpatient population:

What is malnutrition?

Why should we care?

How do we diagnose malnutrition?

What can be done?

An inadequate intake of protein and/or energy over prolonged periods of time resulting in the loss of fat stores and/or

muscle stores. (1)

Characterized by:

Presence and degree of inflammation

No inflammation

Mild – moderate inflammation

Severe inflammation

The severity of malnutrition, based on observation of specific clinical characteristics can be:

Moderate

Severe

Starvation related • Chronic starvation without inflammation

• I.e. anorexia nervosa, chronic food insecurity

Chronic disease-related • Inflammation is present, chronic, and of mild to moderate degree

• I.e. organ failure, cancer, sarcopenic obesity

Acute disease- or injury related • Inflammation is present, acute, and of severe degree

• I.e. major infection, trauma, burns, closed head injury

(1)

Patient must have at least 2 of 6 characteristics to meet definition of malnutrition

Insufficient food intake compared with estimated nutrition requirements

Weight loss over time Loss of muscle mass Loss of fat mass Fluid accumulation Measurably diminished grip strength

Once at least 2 characteristics are identified, malnutrition is categorized as either MODERATE or SEVERE, depending on the severity of the above characteristics

(1)

One could say:

Criteria is met for:

Moderate malnutrition in the context of chronic illness

Severe malnutrition in the context of social or environmental circumstances

Severe malnutrition in the context of acute illness or injury

Pop Quiz

A. Impaired immunity

B. Increased risk of infection

C. Increased frequency of hospital admissions

D. Delayed recovery from illness

E. All of the above

(3)

Malnourished patients:

Have 3 times the risk for surgical site infection (4)

Are twice as likely to develop pressure ulcers (5)

Are at increased risk for falls

45% of patients who fall are malnourished (6)

Those with recent, unintentional weight loss are at increased risk for hospital readmission (7)

Hospitalized patients in medical and surgical

intensive care units experience increased morbidity and mortality related to poor

nutrition status prior to and/or during hospitalization (8)

Negative energy balance during the first 14 days in the ICU is an independent factor of ICU mortality in those needing prolonged mechanical ventilation. (9)

Underfeeding in the ICU has been associated with: Increased rate of infection

Poor wound healing

Reduced respiratory muscle mass

Delayed weaning from mechanical ventilation

Increased ICU LOS

Increased health care costs (10)

Protein-energy deficit occurs in 43 – 88% of critically ill patients (11, 12)

At least 1/3 of patients are malnourished upon hospital admission (11, 13, 14)

Without treatment ~ 2/3 of these will experience further nutritional decline during their hospital stay (15)

An estimated 38% of patients admitted well nourished will experience a nutritional decline during their hospital stay (15)

Both those who are malnourished upon admission and those who

become malnourished during their hospital stay will have increased

healthcare costs.

(15, 16, 17)

Malnourished patients spent an average of 12.6 days in the hospital compared to 4.4 days for well-nourished patients

Resulting in hospital costs almost 3 times higher for malnourished patients

$26,944 versus $9,485

(18)

Hospital infections

Cost ~$33 billion per year (19)

30 day readmissions

Cost ~$26 billion per year (20)

Treatment of hospital malnutrition has been shown to reduced incidence of both

Payment to hospitals can now be withheld for certain preventable conditions including:

Surgical site infections (5)

Pressure ulcers (4)

Falls (6)

All less likely when a patient is adequately nourished

Surgical Infections

Falls

Pressure Ulcers

Hospitals can be penalized for high rates of readmission for:

Heart attack

Heart failure

Pneumonia

In 2013, 2,225 hospitals were penalized $280 million related to excessive readmissions

(21)

Treating hospital malnutrition

Estimated 28% decrease in avoidable

readmissions

BIG SAVINGS

(22)

25% decrease in incidence of

pressure ulcers (23)

14% fewer overall

complications (24)

Average reduced LOS of ~2 days

(25, 26)

Decreased mortality

(27 – 32)

Improved quality of life

(33)

Identify at risk patients

Is Inflammation Present?

Albumin/Prealbumin Patients with low albumin or

prealbumin may or may not be malnourished. Both may be reduced by the systemic response to injury, disease, or inflammation.

White Blood Cell: nonspecific indicators that may

suggest inflammatory response

C-reactive protein: positive acute phase reactant may be measured to help clarify

whether active inflammation is present

These are NOT RELIABLE MARKERS of NUTRITION

They are indicative of the presence of inflammation,

disease severity, morbidity and mortality risk.

In order to diagnose malnutrition – additional

evidence is warranted.

(34 – 35)

ACUTE ILLNESS/INJURY CHRONIC ILLNESS

Inflammation is:

acute and of severe degree

e.g., major infection, burns, trauma or closed head injury

Inflammation is:

chronic and of mild to moderate degree

e.g., organ failure, cancer, rheumatoid arthritis

(1)

Social/Environmental Circumstances (Pure Starvation)

*Chronic starvation without inflammation

* I.e. anorexia nervosa, longstanding food insecurity

(1)

Nutrition Focused Physical Exam

Exam Areas Tips Severe Malnutrition Mild-Moderate

Malnutrition Well Nourished

Subcutaneous Fat Loss

Orbital region—

surrounding the eye

View patient when

standing directly in front

of them, touch above

cheekbone.

Hollow look, depressions,

dark circles, loose skin

Slightly dark circles,

somewhat hollow look

Slightly bulged fat pads,

fluid retention may mask

loss

Upper arm region—

triceps/biceps

Arm bent, roll skin

between fingers; do not

include muscle in pinch.

Very little space between

folds, fingers touch

Some depth pinch, but not

ample

Ample fat tissue obvious

between folds of skin

Thoracic and lumbar

region—ribs, lower back,

midaxillary line

Have patient press hands

hard against a solid object.

Depression between the

ribs very apparent; iliac

crest very prominent

Ribs apparent,

depressions between them

less pronounced; iliac crest

somewhat prominent

Chest is full, ribs do not

show; slight to no

protrusion of the iliac crest

Exam Areas Tips Severe Malnutrition Mild-Moderate

Malnutrition Well Nourished

Muscle Loss

Temple region—

temporalis muscle

View patient when

standing directly in front

of them, ask patient to

turn head side to side.

Hollowing, scooping,

depression Slight depression

Can see/feel well-defined

muscle

Clavicle bone region—

pectoralis major, deltoid,

trapezius muscles

Look for prominent bone.

Make sure patient is not

hunched forward.

Protruding, prominent

bone

Visible in male, some

protrusion in female

Not visible in male, visible

but not prominent in

female

Clavicle and acromion

bone region—deltoid

muscle

Patient arms at side,

observe shape.

Shoulder to arm joint

looks square, bones

prominent, acromion

protrution very prominent

Acromion process may

slightly protrude

Rounded, curves at

arm/shoulder/neck

Scapular bone region—

trapezius, supraspinus,

infraspinus muscles

Ask patient to extend

hands straight out, push

against solid object.

Prominent, visible bones,

depressions between

ribs/scapula or

shoulder/spine

Mild depression or bone

may show slightly

Bones not prominent, no

significant depressions

Dorsal hand—

interosseous muscle

Look at thumb side of

hand; look at pads of

thumb when tip of

forefinger touching tip of

thumb.

Depressed area between

thumb-forefinger Slightly depressed

Muscle bulges, could be

flat in some well-

nourished people

Lower Body Less Sensitive to Change – Muscle Loss

Patellar region—

quadricep muscle

Ask patient to sit with leg

propped up, bent at knee.

Bones prominent, little

sign of muscle around

knee

Knee cap less prominent,

more rounded

Muscles protrude, bones

not prominent

Anterior thigh region—

quadriceps muscles

Ask patient to sit, prop leg

up on low furniture.

Grasp quads to

differentiate amount of

muscle tissue from fat

tissue.

Depression/line on thigh,

obviously thin

Mild depression on inner

thigh

Well rounded, well

developed

Posterior calf region—

gastrocnemius muscle

Grasp the calf muscle to

determine amount of

tissue.

Thin, minimal to no

muscle definition Not well developed

Well-developed bulb of

muscle

Edema

Rule out other causes of

edema, patient at dry

weight

View scrotum/vulva in

activity-restricted patient;

ankles in mobile patient.

Deep to very deep pitting,

depression lasts a short to

moderate time (31-60 s),

extremity looks swollen

(3-4+)

Mild to moderate pitting,

slight swelling of the

extremity, indentation

subsides quickly (0-30 s)

No sign of fluid

accumulation

Exam Areas Tips Severe Malnutrition Mild-Moderate

Malnutrition Well Nourished

(36)

Result of:

Aging (Sarcopenia)

Acute or chronic inflammatory condition

Neurologic impairment

Pure starvation

Lack of physical activity

(34)

Associated with frailty, mortality, and worse surgical and nonsurgical outcomes

Significantly more expensive to care for

For Patients undergoing major general or vascular surgery, decreasing lean core muscle size is associated with increasing cost. Mean Payer Cost:

Sarcopenia : $34,796

Nonsarcopenia: $21,380

(35)

Muscle Loss Depressed area between thumb and forefinger

Severe Muscle Loss = Obvious

depression / line on thigh; thin

Severe Muscle Loss = Thin, minimal to no muscle

definition and firmness

Little sign of muscle around

the patella

Temple Region Severe Muscle Loss = Hollowing, scooping

depression

Severe Fat Loss = Hollow look,

depressions, dark circles, loose skin

Severe Muscle Loss Protruding/Prominent

clavicle bone

Severe Muscle Loss Scapular bone/upper

back Prominent bones with

definitive angles. Depressions easily seen.

Severe muscle loss Shoulder appears square with sharp

angle

Severe fat loss = very little

space between folds, fingers

touch

Severe fat loss =

Ribs very apparent. iliac crest

very prominen

t

Presence of 2 or More Characteristics?

Weight Loss Amount Time Frame

Nutritional Intake <50% <75% Time Frame

Functional Status Muscle Wasting

Mild, Moderate, or Severe

Fat Loss Mild, Moderate, or Severe

Edema Mild, Moderate, or Severe

(1)

Malnourished??

Yes or No?

Moderate or Severe?

Weight loss: 1-2% -- 1 week 5% -- 1 month 7.5% -- 3 months

Energy intake: <75% for >7 days

Body fat: Mild depletion

Muscle mass: Mild depletion

Fluid accumulation: Mild

Weight loss: 5% -- 1 month 7.5% -- 3 months 10% -- 6 months 20% -- 1 year

Energy intake:

<75% for >1 month

Body fat: Mild depletion Muscle mass: Mild depletion Fluid accumulation: Mild

Weight loss 5% -- 1 month 7.5% -- 3 months 10% -- 6 months 20% -- 1 year

Energy intake - <75% for >3 months

Body fat - Mild depletion Muscle mass - Mild depletion Fluid accumulation – Mild

Weight loss >2% -- 1 week >5% -- 1 month >7.5% -- 3 months

Energy intake - <50% for >5 days

Body fat - Moderate depletion Muscle mass - Moderate depletion Fluid accumulation – Moderate to severe

Weight loss >5% -- 1 month >7.5% -- 3 months >10% -- 6 months >20% -- 1 year

Energy intake - <75% for >1 month

Body fat - Severe depletion

Muscle mass - Severe depletion

Fluid accumulation – Severe

Weight loss >5% -- 1 month >7.5% -- 3 months >10% -- 6 months >20% -- 1 year

Energy intake - <50% for >1 month

Body fat - Severe depletion Muscle mass - Severe depletion Fluid accumulation – Severe

(37)

YES NO

Acute Illness or Injury

Chronic Illness Social/Environmental

Presence of 2 or More Characteristics?

Yes No

Not Malnourished

Malnourished

Moderate Severe

Nutrition Risk Identified

Inflammation Present?

(34)

Pop Quiz

Mr P is a 51 year old male admitted to the CVICU for heart failure exacerbation . Found to have a stage 3 pressure ulcer to his left heel – present on admission. PMH: ESRD on HD, HTN, DM type 2 Height: 183cm / 72in Admit Weight: 123kg Dry Weight (per patient report): 117kg BMI: 34.9 – class 1 obesity (based on dry weight) Weight History: Pt reports significant weight loss a few months back during a hospitalization at an OSH. 01/12/16 123.5kg 09/08/15 149.19kg Oral Intake History: Pt reports good appetite / intake currently Labs: BUN: 46 Creat: 7.37 GFR: 8 K+: 5.9 Nutrition Focused Physical Exam Moderate to Severe Temporal Wasting and depletion of orbital fat pads. Clavicle is quite prominent. Unable to visualize other muscle wasting secondary to body habitus/edema. Skin Breakdown: Stage 3 Pressure Ulcer - left heel

A. Severe malnutrition in the context of chronic illness

B. Moderate malnutrition in the context of chronic illness

C. Moderate malnutrition in the context of social/environmental situation

D. Does not meet criteria for malnutrition

Four Part Action Plan

Improve recognition of at risk patients Malnutrition is:

under-recognized

under-treated (33)

Screen, assess, and diagnose patients at malnutrition risk Difficulty chewing/swallowing

Age > 70 years

History of decreased appetite

History of unintentional weight loss

Regular use of oral nutrition supplements

Dependence on enteral/parenteral nutrition support

History of gastric bypass

Implement interventions without delay

For example: Early initiation of enteral nutrition support

Minimizing cessation of enteral nutrition/NPO status

Liberalization of diet order to encourage p.o. intake

Addition of snacks

Assistance with meal set up and feeding

Educating patients on the importance of eating enough

Addition of oral nutrition supplement

ONS are consistently shown to have beneficial clinical effects with economic implications (38)

Significant increase in total protein/energy intake with little suppression of normal food intake (38)

Use of high protein ONS is associated with improved functional outcomes (handgrip strength), decrease LOS, reduction in hospital readmission rates (39)

Readmission reductions

26 - 29% readmission rate with ONS vs 40- 48% without ONS (40, 41)

19% reduction in complications – including infection rates, healing of surgical wounds, pressure ulcers (42)

Empower all clinicians to address patients’ nutritional needs

Educate all clinicians on the recognition and diagnosing of malnutrition

Engage nurses in understanding malnutrition risk factors and create policies that allow nurses to help provide nutrition care

Initiate a nutrition care plan within 48 hours of admission for patients with or at risk of malnutrition

Integrate the dietitian into the interdisciplinary ICU team

Consult the dietitian immediately if malnutrition is suspected

Consider allowing registered dietitians to have ordering privileges for diet orders, oral nutrition supplements, and vitamins/minerals

(33)

Create culture where nutrition is seen as a priority for improving: Care Quality Cost

Create an open dialogue on potential institutional changes For example:

Easier availability of snacks/supplements Designated and protected meal times Improved quality of hospital food Enhanced menu selection Use of standardized written instructions for nutrition care at

home post-discharge and/or prior to admission for elective procedures (33)

Case Study

Mr K is a 70yo Male admitted to the Neuro ICU for rule out CVA. PMH: CAD, HTN, HLD, Chronic Alcoholism, and previous strokes. Height: 68in Current Weight: 80.8kg BMI: 26.99 (adequate for age) Weight History: 87.9kg 08/04/16 – 1 month ago 102kg 01/03/16 -7 months ago Oral Intake: Pt’s wife reports that he has been in and out of the hospital 6 times over the past 8 months. Pt dislikes hospital food. His oral intake is fair at home (eating ~50% of his meals) but very poor during his admissions. This has resulted in weight loss. Labs: WBC 11.8 Physical Exam: No pressure ulcers indicated Mild Muscle Wasting at temporal and clavicle regions

Does Mr. K. meet criteria for malnutrition??

A. Moderate malnutrition in the context of chronic disease

B. Moderate malnutrition in the context of social/environmental situation

C. Severe malnutrition in the context of chronic disease

C. Severe malnutrition in the context of acute illness/injury

- Liberalization of diet order to regular diet

- Addition of oral nutrition supplement

- Assistance with tray set up/feeding

- Addition of daily MVI, thiamine, folic acid

(given history of ETOH)

Malnutrition is under-recognized and often untreated although it is associated with increased:

Complication rates

Length of stay

Readmission rates

Mortality

Diagnosis and treatment of malnutrition has been consistently shown to improve patient outcomes (33)

We need to look at changing the attitude about the importance of hospital nutrition in both patients and providers (43)

Consider nutritional status an essential part of the patient’s condition

Make nutrition interventions a core component of medical therapy (33)

Better nourished patients translate to:

Improved care

Improved quality of life

Decreased costs (33)

We Can’t Afford Not To

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