malnutrition: where are we headed? - dietitians in … symposium presentations...malnutrition: where...

Malnutrition:

Where are we headed?

Kris M. Mogensen, MS, RD-AP, LDN, CNSC

Team Leader Dietitian

Brigham and Women’s Hospital

Instructor

Boston University College of Health and Rehabilitation Sciences:

Sargent College

[email protected]

Disclosures

• I have no disclosures related to this

topic

• It helps to look back before we look

forward, so:

– Review prior malnutrition efforts

– What’s happening with Academy-

ASPEN characteristics

– Where are we headed?

Objectives

Kickin’ it Old School

JAMA 1936

Nutrition Today

1974

JPEN

1977 – Issue 1!!

“Old” Evaluation Parameters

• % IBW

• % UBW

• Presence of fat/muscle wasting

• Presence of edema

• Adequacy of intake

• Circulating proteins

• Anergy

• Other direct anthropometric measurements

Old Malnutrition Diagnoses

• Kwashiorkor

• Marasmus

• Mild, moderate, severe protein-calorie

malnutrition

• Protein-calorie malnutrition, NOS

Old Malnutrition Diagnoses

Blast from the Past!

From ~ 1992!

# of

Criteria Wt loss IBW wasting

Inadequate

energy intake Albumin*

Severe PCM 3 > 15% in 6

mo. < 70% yes yes < 2.1

Moderate

PCM 2

10%-15%, in

6 mo. 70%-84% no no < 2.7

Mild PCM 2 5%-9% in 6

mo. 85%-94% no no < 3.4

Marasmus 3

5% over one

mo., 7.5

over three

mo., 10%

over six mo.

<94% yes yes WNL or slightly

decreased

Unspecified

PCM

A patient at nutritional risk who may have a single nutrient deficiency,

multiple micronutrient deficiencies, overt fat/muscle wasting without

supporting weight history to fit into another category, prolonged

hypocaloric intake and high metabolic demand, etc.

BWH Old Criteria

*RDs trained not to use if inflammation or other confounder present

Malnutrition Outcomes:

Old Characteristics

CCM 2015

CCM 2015

JPEN epub 2016; print Feb 2017

JPEN epub 2016

Moving into modern times…

Etiology-Based Malnutrition Diagnoses

From: White JV et al. Consensus statement: Academy of Nutrition and Dietetics and American

Society for Parenteral and Enteral Nutrition: Characteristics recommended for the identification

and documentation of adult malnutrition (undernutrition). JPEN 2012

2012 Malnutrition Clinical

Characteristics Parameters

• Insufficient energy intake

• Weight loss

• Loss of muscle mass

• Loss of subcutaneous fat

• Localized or generalized fluid

accumulation that may sometimes mask

weight loss

• Diminished functional status as measured

by hand grip strength From: White JV et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and

Enteral Nutrition: Characteristics recommended for the identification and documentation of adult malnutrition

(undernutrition). JPEN 2012

Evaluation of Energy Intake

Kondrup K. Clin Nutr. 2001

Intake <75%

of needs, no

weight

maintenance

or gain

Weight Loss Evaluation

Physical Examination

Hand Grip Strength

Where are we headed?

First stop: Validation!

Validation of the Academy/ASPEN Malnutrition Clinical

Characteristics. Hand RK et al. JAND 2016

Current research with 2012 Adult

Malnutrition Clinical Characteristics

• Nicolo M et al. Feasibility of accessing data in hospitalized patients to

support diagnosis of malnutrition by the Academy- A.S.P.E.N.

malnutrition consensus recommended clinical characteristics. JPEN

2014;38:954-959

• Hand RK et al. Validation of the Academy/ASPEN Malnutrition Clinical

Characteristics. J Acad Nutr Diet. 2016

• Hiller LD et al. Difference in composite end point of readmission and

death between malnourished and nonmalnourished veterans assessed

using Academy of Nutrition and Dietetics/American Society for

Parenteral and Enteral Nutrition Clinical Characteristics. JPEN epub Sept

2016

• Mulasi U et al. Malnutrition identified by the Academy of Nutrition and

Dietetics and American Society for Parenteral and Enteral Nutrition

consensus criteria and other bedside tools is highly prevalent in a

sample of individuals undergoing treatment for head and neck cancer.

JPEN epub Oct 2016

Feasibility of accessing data in hospitalized patients to

support diagnosis of malnutrition by the Academy-

A.S.P.E.N. malnutrition consensus recommended clinical

characteristics. Nicolo M et al. JPEN 2014

Validation of the Academy/ASPEN

Malnutrition Clinical Characteristics. Hand RK et al. JAND 2016

Clinical Characteristic Evaluated?

Intake 96%

Wgt loss 92%

Muscle 98%

Fat 100%

Edema 98%

Hand grip 64%

28 patients enrolled in the study

Validation of the Academy/ASPEN Malnutrition

Clinical Characteristics. Hand RK et al. JAND 2016

• Was there agreement between RDs?

– 24 of 28 had evaluation done by 2 RDs

• Context: agreed ~ 88% of the time

• Diagnosis: agreed for ~ 67% of pts

Validation of the Academy/ASPEN

Malnutrition Clinical Characteristics. Hand RK et al. JAND 2016

• Full outcome data for 11 pts

– Malnourished pts had

• longer LOS

• higher charges

• more frequent ED visits

• More frequent readmissions

Difference in composite end point of readmission and death between

malnourished and nonmalnourished veterans assessed using

Academy of Nutrition and Dietetics/American Society for Parenteral

and Enteral Nutrition Clinical Characteristics. Hiller LD et al. JPEN epub 2016

• Retrospective medical record review

• Used all characteristics except hand grip

strength

• Matched malnourished vs nonmalnourished:

202 in each group

• Composite end point: 30 day readmission

rate and 90 day mortality rate

Difference in composite end point of readmission and death between

malnourished and nonmalnourished veterans assessed using

Academy of Nutrition and Dietetics/American Society for Parenteral

and Enteral Nutrition Clinical Characteristics. Hiller LD et al. JPEN epub 2016

Comparisons to other

markers…

Malnutrition Identified by the Academy of Nutrition and Dietetics and

American Society for Parenteral and Enteral Nutrition Consensus

Criteria and Other Bedside Tools is Highly Prevalent in a Sample of

Individuals Undergoing Treatment for Head and Neck Cancer. Mulasi U et al. JPEN epub 2016

Validation, refining the

characteristics, and

more…where do we go from

here?

Functional Status and

Outcomes

CCM 2016

Surgery 2016


Outcomes • Formal PT assessment using the

Functional Independence Measure

– Independent, low, intermediate, high, and very

high risk

• High & very high risk

– Increased odds of 90-day post-discharge

mortality in ICU and trauma patients

– Higher prevalence of malnutrition in these

groups

Crit Care

Med. 2016


Outcomes

• Can we collaborate with other

colleagues evaluating patients? – Could the PT scoring system be part of our

malnutrition characteristics in adults?

– Are our OT colleagues measuring hand grip

strength?

Measures of Muscle Mass

• What are the roles of

– BIA

– CT

– Ultrasound

• Will these move into prime time?

Role of Metabolomics?

Mogensen et al. JPEN

2017

Coding and Data Collection

• We need to continue to work on

getting malnutrition coded

appropriately

• Not just a $$$ issue, but allows for

ongoing research for prevalence and

outcomes

Data Collection and Storage

• If you are still in your building phase

of your EHR or you actually have

programmers who want to work with

you…

– Document data in a structured format

– Limit free text for data

Treatment of Malnourished

Patients

• Is there a difference in clinical

response in malnourished vs. well

nourished patients?

• How do we study this?

Conclusions

• Validation studies of current malnutrition

characteristics are in progress

• Will there be refinement of these characteristics

in the future?

• Keep collecting data and outcomes! Push for

appropriate coding!

• I hope that future research includes other

evaluation tools to expand the characteristics

• Finally, my hope is that future research evaluates

impact of nutrition interventions for malnourished

patients

Thank you!

malnutrition: where are we headed? - dietitians in … symposium presentations...malnutrition: where...

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