Malnutrition By 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 ulcer

development

• The annual burden of disease-associated malnutrition across 8 diseases in the

U.S. is $156.7 billion

What is malnutrition? “An acute, subacute or chronic state of nutrition in which a combination of varying

degrees of overnutrition 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 • Body mass index less than 18.5 kg/m2 or greater than 25 kg/m2 • Chronic disease • Increased metabolic requirements • Modified Diet • Inadequate nutrition intake, including not receiving food 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 starvation without

inflammation (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, sarcopenic

obesity)

• Acute Illness/ Injury - Moderate – severe inflammation for less than 3 months

(ex. infection, burns, trauma or pancreatitis, major surgery)

Diagnosis Criteria Weight loss: considers hydration status; weight change over time is represented as a percentage

of weight loss 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 (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, or

vulvar/scrotal edema)

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- </= 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 Exam

BIDMC approved abbreviation: NFPEx

• A head to toe examination to determine micronutrient 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 wasting

Patellar and Quadricep muscle wasting

NFPEx

Things to look out for in nutrition notes… NFPEx

Muscle loss

Fat loss

Skin

Head/hair

Eyes/Nose/Mouth

Hands/Nails

GI/Abdomen

Lower Extremity

Assessment:

Adequately nourished, obese, malnourished

(mild/moderate/severe)

Versus

Patient at risk of malnutrition due to: poor po

intake, NPO/ hypocaloric intake, other

Estimated Daily needs of kcal, protein, fluid

Estimation of current/previous intake

Moderate-severe temporal

wasting, somewhat

prominent iliac crest,

protruding acromion

process,

angular stomatitis

<50%

of usual

intake x

7 days

N/V x 3

days

Malnutrition definitions

ICD-10 Code: E43 Severe Malnutrition

Severe Malnutrition in Context of Acute Illness / Injury (<3 months)

Severe Malnutrition in Context of Chronic Illness (>3 months)

Severe Malnutrition in Context of Social / Behavioral / Environmental Circumstances

Weight Loss – is evaluated in light of other clinical findings including hydration. Weight change over time is reported as percentage of weight loss from baseline.

Weight Loss

> 2% in 1 week

> 5% in 1 month

> 7.5% in 3 months

Weight Loss

> 5% in 1 month

> 7.5% in 3 months

> 10% in 6 months

> 20% in 12 months

Weight Loss

> 5% in 1month

> 7.5% in 3 months

> 10% in 6 months

> 20% in 12 months

Intake – R.D. obtains diet history and estimates energy needs. Suboptimal intake is determined as a percentage of estimated need over time.

Energy Intake ≤ 50% energy intake compared to estimated energy needs for ≥ 5 days

Energy Intake ≤ 75% energy intake compared to estimated energy needs for ≥ 1 month

Energy Intake ≤ 50% energy intake compared to estimated energy needs for ≥ 1 month

Physical Assessment – loss of subcutaneous fat (i.e. orbital, triceps, fat overlying ribcage)

Body Fat Moderate depletion

Body Fat Severe depletion

Body Fat Severe depletion

Physical Assessment – loss of muscle (i.e. temples, clavicles, shoulders, scapula, thigh and calf)

Muscle Mass Moderate depletion

Muscle Mass Severe depletion

Muscle Mass Severe depletion

Physical Assessment - general or local fluid accumulation (i.e. extremities, ascites or vulvar / scrotal edema)

Fluid Accumulation Moderate to Severe

Fluid Accumulation Severe

Fluid Accumulation Severe

Functional Assessment – based on standards supplied by manufacturer of dynamometer

Reduced Grip Strength Not recommended in Intensive Care Setting

Reduced Grip Strength Measurably reduced for age and gender

Reduced Grip Strength Measurably reduced for age and gender

ICD-10 Code: E44.0 Moderate Malnutrition

Non-Severe Malnutrition in Context of Acute Illness / Injury (< 3 months)

Non-Severe Malnutrition in Context of Chronic Illness (> 3 months)

Non-Severe Malnutrition in Context of Social / Behavioral / Environmental Circumstances

Weight Loss – is evaluated in light of other clinical findings including hydration. Weight change over time is reported as percentage of weight loss from baseline.

Weight Loss

1 to 2% in 1 week

5% in 1 month

7.5% in 3 months

Weight Loss

5% in 1month

7.5% in 3 months

10% in 6 months

20% in 12 months

Weight Loss

5% in 1 month

7.5% in 3 months

10% in 6 months

20% in 12 months

Intake – R.D. obtains diet history and estimates energy needs. Suboptimal intake is determined as a percentage of estimated need over time.

Energy Intake < 75% energy intake compared to estimated energy needs for > 7 days

Energy Intake < 75% energy intake compared to estimated energy needs for ≥ 1 month

Energy Intake < 75% energy intake compared to estimated energy needs for ≥ 3 months

Physical Assessment – loss of subcutaneous fat (i.e. orbital, triceps, fat overlying ribcage)

Body Fat Mild depletion

Body Fat Mild depletion

Body Fat Mild depletion

Physical Assessment – loss of muscle (i.e. temples, clavicles, shoulders, scapula, thigh and calf)

Muscle Mass Mild depletion

Muscle Mass Mild depletion

Muscle Mass Mild depletion

Physical Assessment – general or local fluid accumulation (i.e. extremities, ascites or vulvar / scrotal edema)

Fluid Accumulation Mild

Fluid Accumulation Mild

Fluid Accumulation Mild

Functional Assessment – based on standards supplied by manufacturer of dynamometer

Reduced Grip Strength Not applicable

Reduced Grip Strength Not applicable

Reduced Grip Strength Not applicable

• Diagnosis of adult malnutrition

should be based on two or more of

the criteria

• Criteria apply at ALL BMI levels

Case Study J.M. 72YO F who reports 6-7 months of decreased appetite 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, thyroid 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/nutrient 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 death, 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

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