Guest post by Alysia Johansson MS RD CDN, Clinical Nutrition Coordinator at The Mount Sinai Hospital. Alysia has been at Mount Sinai since 2011 where she works as part of the interdisciplinary Cardiothoracic ICU team. Alysia also coordinates malnutrition efforts for the Clinical Nutrition Department and will be presenting at an upcoming conference on April 21 2016 at The Mount Sinai Hospital, Malnutrition: Implementing Strategies for Medical Nutrition Therapy.
Malnutrition has been recognized as a problem in hospitalized patients for over 40 years. Malnutrition is any disorder of nutrition resulting from unbalanced or insufficient diet, increased needs, or impaired absorption, utilization, or excretion of nutrients – all in the presence or absence of inflammation. Malnutrition contributes to a multitude of poor patient outcomes including decreased function and quality of life, decreased wound healing, anemia, increased risk of infection, increased risk for developing pressure ulcers, increased risk of surgical complications, increased mortality, increased frequency of hospital admissions and increased length of hospital stay. Aside from being detrimental to care, all of these outcomes lead to higher healthcare costs. For these reasons, it is imperative that clinicians be aware of the signs of malnutrition, and take proper measures to enhance the nutritional status of their patients.
In 2007, The Centers for Medicare and Medicaid Services (CMS) added malnutrition to its disease severity component in recognition of the fact that malnourished patients require additional care and resources as compared to well-nourished patients with the same diagnoses. However, diagnostic criteria for malnutrition had not yet been established. In 2010, the National Center for Health Statistics (NCHS) requested and received commentary on existing malnutrition codes descriptors from the Academy of Nutrition and Dietetics (the Academy) and the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.).
The Academy and A.S.P.E.N. formed a Malnutrition Workgroup to develop a framework for diagnosing malnutrition. They proposed an etiology-based approach focusing on the inflammatory response, with specific criteria recommended for the diagnosis of malnutrition. They described 6 general characteristics of malnutrition: inadequate energy intake, unintentional weight loss, presence of muscle wasting, presence of subcutaneous fat wasting, fluid accumulation (which may mask weight loss), and decreased functional status. A patient must have at least two of the aforementioned criteria present in order to diagnose malnutrition. The degree and duration of the diagnostic criteria are dependent on the inflammatory status of the patient, and determine whether the malnutrition qualifies as severe or non-severe. The Academy/ A.S.P.E.N. Malnutrition Workgroup does not recommend the diagnosis of mild malnutrition in the adult population, as there is insufficient evidence to distinguish the difference between mild and moderate forms of malnutrition.
The first type of malnutrition, Starvation-Related, is chronic starvation in the absence inflammation. The body enters a starvation state with decreased metabolic rate, mobilization of fat stores, and preservation of skeletal muscle. This type of malnutrition is seen most often in under-developed countries, though may be seen in the elderly with limited access to food, or in the behavioral health population.
The second type of malnutrition, the type most frequently encountered in the hospital setting, is Chronic Disease-Related Malnutrition. This is malnutrition occurring in the presence of chronic inflammation of a mild to moderate degree. When the body begins to shift into a catabolic state, normal metabolic pathways are altered. In chronic diseases, such as heart failure or cancer, the liver reduces the production of transport proteins such as albumin and prealbumin, and up-regulates production of positive acute-phase proteins such as C-reactive protein. Anorexia may occur, exacerbating symptoms. This leads to the classic picture seen in cancer or cardiac cachexia patients.
The third and final type of malnutrition is Acute Disease or Injury-Related Malnutrition. This is malnutrition that occurs due to the extreme changes in metabolism in the presence of an acute and severe inflammatory response. This is seen most frequently in trauma, burn patients, and those who are critically ill.
Once the degree, and more importantly the etiology of malnutrition have been identified, dietitians and medical practitioners can intervene to halt and hopefully reverse the malnutrition. In the case of starvation-related malnutrition, promoting adequate calories and protein via food or oral nutrition supplementation is enough to curtail this type of malnutrition. In chronic-disease related malnutrition, it is imperative to make sure the patient is adherent to medical management of the disease to minimize the inflammatory processes. Additional interventions such as appetite stimulants or alternate nutrition support (i.e. enteral or parenteral nutrition) may be necessary to meet the increased metabolic demand in these patients. Nutritional intervention in the critically ill, specifically early enteral nutrition support, has been shown to aid in attenuating the drastic metabolic shifts that occur in the presence of acute inflammation.
The Clinical Nutrition department at Mount Sinai Hospital utilizes the Academy and A.S.P.E.N. criteria to identify individuals who are malnourished. It is key for all healthcare clinicians to familiarize themselves with these criteria in order to move toward a standardized practice for the diagnosis and documentation of malnutrition. Once this takes place, it will be easier to determine the prevalence of malnutrition as well as to research methods of intervention.