Malnutrition matters in healthcare Screen & Assess

Transcription

1 Malnutrition matters in healthcare Screen & Assess Krystel Ouaijan, RDN, MSc Nutrition Support Dietitian in Saint George Hospital UMC PhD candidate in University of Geneva

2 Workshop Part 1 Lecture: Introduction and statistics Etiology of malnutrition Screening of malnutrition Overview of all screening tools practical examples Taking screening one step further Practical examples on Physical examination Implications of malnutrition from A to Z Management of malnutrition Case study of head and neck cancer

3 An Opening Thought

4 History JAMA 1974 Butterworth CE Jr. Journal of the American Medical Association 1974; 230 (6) :879. Compher at al. Journal of the American Dietetic Association 2016; 116 (5):

5 International Consensus Guideline Committee Jensen et al. Clinical Nutrition 2010; 29:

6 Causes for Malnutrition Vicious cycle Norman et al. Clinical Nutrition 2008; 27: 5-15.

7 Prevalence of Malnutrition in Hospitals Weighted mean percentage of US and European countries is documented to be 31.4% 60% 50% 48% 50% 40% 38% UK USA 30% 20% 20% 27% 20% Brazil Germany Sweden 10% Latin America 0% Norman et al. Clinical Nutrition 2008; 27: Country

8 Malnutrition Is Common Across All Hospital Wards 60% 54% 60% 50% 40% 30% 20% 10% 0% 29% 28% 15% 41% 31% Internal Medicine Surgery Intensive Care Geriatrics Orthopedics Oncology Gastroenterology Fontes et al. Clinical Nutrition 2014; 33 (2): Pirlich et al. Digestive Diseases 2003; 1:

9 Malnutrition Increases during Hospital Stay A: 9,6 % of well nourished patients became malnourished during hospital stay. B: During hospital stay, most patients being malnourished on admission remained malnourished at discharge (72 %). Álvarez-Hernández J et al. Nutrition in Hospitals 2012; 27 (4):

10 What about Lebanon? There is no national data. One study 1993: 53% of patients admitted to the department of surgery had evidence of malnutrition. No clear cut criteria We have initiated a national study about prevalence of malnutrition in hospitals across Lebanon. Aoun et al. The Lebanese Medical Journal 1993; 41:

11 What about Lebanon? Screening done either by dietitians or by nurses after training over one month period. Screening tool used Nutrition Risk Screening NRS. Validated for all hospitalized patients Easy-to-use tool (2-3 min) We presented some pilot studies done in ESPEN congress (2016) and ASPEN (2018). Kondrup et al. Clinical Nutrition 2003; 22:

12 Prevalence of Malnutrition in Beirut Governmental hospital and two private university hospitals 1 month period of admissions 922 patients Prevalence of malnutrition (moderate and high): 32.8% Patients classified according to risk of malnutrition 13.2% 19.6% 67.2% Very closed to worldwide prevalence Low Moderate High Ouaijan et al. Clinical Nutrition, 2016; ESEPN abstract book

13 In other Words 1 in 3 of people admitted into hospital in Beirut are already malnourished. Ouaijan et al. Clinical Nutrition, 2016; ESEPN abstract book

14 Difference in Prevalence of Malnutrition by Type of Hospital P < 0.01 Prevalence of Malnutrition 60.0% 40.0% 24.8% 43.4% 20.0% 0.0% Private hospital Governmental hospital Private hospital Governmental hospital Unpublished data 14

15 Prevalence of Malnutrition in the ICU For 1 year period: 117 critically ill patients (LOS > 3 days) Prevalence of malnutrition (moderate and high): 76 % ICU Patients classified according to risk of malnutrition 24% 76% Low Moderate/High Ouaijan et al. ASPEN congress 2018.

16 Screening of Malnutrition The Joint Commission mandates that hospital conduct nutrition screening within 24 hours of hospital admission. Referral to specialists for further nutrition assessment and targeted nutrition intervention. 70% of cases of malnutrition are frequently unrecognized due to lack of screening and awareness among healthcare professionals O Flynn et al. Clinical Nutrition 2005; 24:

17 Nutrition Screening Screening as defined by the US Preventive Services Task Force as those preventive services in which a test or standardized examination procedure is used to identify patients requiring special intervention Nutrition screening is a supportive system; not a step within the Nutrition Care Process but a critical antecedent step. It identifies clients who would benefit from nutrition care or MNT. Nutrition screening is a supportive system; not a step within the Nutrition Care Process. Lacey et al. Journal of The American Dietetic Association 2003;103:

18 Nutrition Screening The followings should be considered: Accuracy Specificity: Can it identify patients with a condition? Sensitivity: Can it identify those who do not have the condition? Effectiveness as related to likelihood of positive health outcomes if intervention is provided. Quick, easy to administer and cost-effective. It is more practical to incorporate it into the admission assessment. Lacey et al. Journal of The American Dietetic Association 2003;103:

19 Nutrition Screening Many validated tools for nutrition risk screening exist: Malnutrition Screening Tool: MST Malnutrition Universal Screening Tool: MUST Nutrition Risk Screening: NRS Malnutrition Nutrition Assessment: MNA Subjective Global Assessment: SGA Adult Nutrition Support Core Curriculum, 3 rd edition, US: ASPEN.

20 Malnutrition Screening and Assessment Malnutrition Screening Tool MST three-question tool assessing recent weight loss, appetite loss and presence of illness validated for use in general medical and surgical patients. Please apply it to the following patient: An 85 year old female was admitted to the geriatric unit with pneumonia. She doesn t walk a lot but can get out of bed alone. She was found to have a pressure ulcer stage 2 in the coccygeal area. The patient is well oriented. Her height is 155cm and her weight is 50kg. She looks tired but not wasted. She used to be 55kg 3m ago. She has recently low appetite and is eating only one meal per day. Stratton et al. British Journal of Nutrition 2004; 92:

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22 Malnutrition Screening and Assessment Malnutrition Universal Screening Tool MUST developed by BAPEN to screen all adults, even if weight and/or height cannot be measured. 5-step screening tool. Please apply it to the previous patient. An 85 year old female was admitted to the geriatric unit with pneumonia. She doesn t walk a lot but can get out of bed alone. She was found to have a pressure ulcer stage 2 in the coccygeal area. The patient is well oriented. Her height is 155cm and her weight is 50kg. She looks tired but not wasted. She used to be 55kg 3m ago. She has recently low appetite and is eating only one meal per day. Stratton et al. British Journal of Nutrition 2004; 92:

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24 Malnutrition Screening and Assessment Nutritional Risk Screening NRS more developed form validated for all hospitalized patients. Recommended by ESPEN. It contains the nutritional components of MUST, and in addition, a grading of severity of disease as a reflection of increased nutritional requirements. Please apply it to the following patient: An 85 year old female was admitted to the geriatric unit with pneumonia. She doesn t walk a lot but can get out of bed alone. She was found to have a pressure ulcer stage 2 in the coccygeal area. The patient is well oriented. Her height is 155cm and her weight is 50kg. She looks tired but not wasted. She used to be 55kg 3m ago. She has recently low appetite and is eating only one meal per day. Kondrup et al. Clinical Nutrition 2003; 22:

25 Nutrition Risk Screening NRS Step 1: Initial Screening Is BMI < 18.5? (BMI = weight / height m2) YES NO Has the patient lost weight within the last 3 month? YES NO Has the patient had a reduced dietary intake in the last week? YES NO Is the patient severely ill? (e.g. in intensive therapy) YES NO Move to Step 2 Kondrup et al. Clinical Nutrition 2003; 22: Copyright Fresenius Kabi

26 Nutrition Risk Screening NRS Step 2: Final Screening Impaired nutritional status Severity of disease ( increase in requirements) Absent Score 0 Mild Score 1 Moderate Score 2 Severe Score 3 Normal nutritional status Wt loss >5% in 3 mths or food intake below 50-75% of normal requirement in preceding week Wt loss >5% in 2 mths or BMI impaired general condition or food intake 25-60% of normal requirement in preceding week Wt loss >5% in 1 mths (>15% in 3 mths) or BMI < impaired general condition or food intake 0 25% of normal requirement in preceding week Absent Score 0 Mild Score 1 Moderate Score 2 Severe Score 3 Normal nutritional requirements Hip fracture, Chronic patients, in particular with acute complications cirrhosis, COPD*. Chronic hemodialysis, diabetes, oncology Major abdominal surgery, Stroke, Severe pneumonia, hepatologic malignancy Head injury, Bone marrow transplantation, Intensive care patients (APACHE>10) Age if 70 years: add 1 to total score above = age-adjusted total score Kondrup et al. Clinical Nutrition 2003; 22: Copyright Fresenius Kabi

27 Krystel Ouaijan NFSC 224 Module 2 Nutrition Risk Screening NRS Step 3: Count the Score Score 3: the patient is nutritionally at risk and a nutritional care plan is initiated Score < 3: weekly rescreening of the patient. If the patient e.g. is scheduled for a major operation, a preventive nutritional care plan is considered to avoid associated risk status Kondrup et al. Clinical Nutrition 2003; 22: Copyright Fresenius Kabi

28 Malnutrition Screening and Assessment Mini Nutrition Assessment MNA 5-item screening and 18- item assessment including anthropometrical, psychosocial, medical and dietary factors validated for elderly patients. Please apply it to the previous patient. An 85 year old female was admitted to the geriatric unit with pneumonia. She doesn t walk a lot but can get out of bed alone. She was found to have a pressure ulcer stage 2 in the coccygeal area. The patient is well oriented. Her height is 155cm and her weight is 50kg. She looks tired but not wasted. She used to be 55kg 3m ago. She has recently low appetite and is eating only one meal per day. Barker et al. International Journal of Environmental Research and Public Health 2011; 8:

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30 Malnutrition Screening and Assessment Subjective Global Assessment SGA questionnaire includes data on weight change, presence of edema and fats loss, dietary intake change, gastrointestinal symptoms and changes in functional capacity. Mostly used by clinicians. Please apply it to the previous patient. An 85 year old female was admitted to the geriatric unit with pneumonia. She doesn t walk a lot but can get out of bed alone. She was found to have a pressure ulcer stage 2 in the coccygeal area. The patient is well oriented. Her height is 155cm and her weight is 50kg. She looks tired but not wasted. She used to be 55kg 3m ago. She has recently low appetite and is eating only one meal per day. Barker et al. International Journal of Environmental Research and Public Health 2011; 8:

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32 Adult Nutrition Support Core Curriculum, 3 rd edition, US: ASPEN.

33 Survey of Clinical Practices in Lebanon 41 Lebanese hospitals 40 Hospitals performing Malnutrition Screening Yes No Abi Salehet al. Clinical Nutrition, :

34 Taking Screening a Step Further Handgrip Strength Measurement of muscle strength Sensitive to loss of muscle mass Nutrition Focused Physical Examination NFPE Necessary for diagnosis and assessment Determine ICD codes Three areas: Subcutaneous fat los Muscle loss Fluid accumulation Matos et al. European Journal of Clinical Nutrition 2007; 61: Modarski et al. Journal of the Academy of Nutrition and Dietetics 2017; 117:

35 Handgrip Strength Study on 314 patients in two public hospitals in Europe: NRS screening and HGS Results: Patients with increasing HGS had an independent decreasing risk of being nutritionally-at-risk. Each additional kg of HGS was associated with a 4% reduction of risk of a LOS > 7 days. Matos et al. European Journal of Clinical Nutrition 2007; 61:

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37 Nutrition-focused physical findings Academy of Nutrition and Dietetics, Nutrition Focused Physical Exam Pocket Guide, 2 nd edition.

38 Nutrition-focused physical findings Academy of Nutrition and Dietetics, Nutrition Focused Physical Exam Pocket Guide, 2 nd edition.

39 Nutrition-focused physical findings Academy of Nutrition and Dietetics, Nutrition Focused Physical Exam Pocket Guide, 2 nd edition.

40 Nutrition-focused physical findings Academy of Nutrition and Dietetics, Nutrition Focused Physical Exam Pocket Guide, 2 nd edition.

41 Let s see some practical pictures!

42 Academy of Nutrition and Dietetics, Nutrition Focused Physical Exam Pocket Guide, 2 nd edition.

43 Academy of Nutrition and Dietetics, Nutrition Focused Physical Exam Pocket Guide, 2 nd edition.

44 Academy of Nutrition and Dietetics, Nutrition Focused Physical Exam Pocket Guide, 2 nd edition.

45 Nutrition Assessment Screening should be followed directly by assessment as part of nutrition care plan from RD. Accurate diagnosis should be well identified Mueller et al. Journal of Parenteral and Enteral Nutrition 2011; 35:

46 AA-CCM Diagnostic Tool Clinical Characteristic Cut-off point for severe malnutrition 1. Energy intake 50% of estimated energy requirement 2 of 6 characteristics for 5 days for diagnosis with 2. Weight loss >2% in 1 week severe malnutrition >5% : in 1 month >7.5% in 3 months to be included in ICD Body fat Moderate loss of subcutaneous fat (e.g. orbital, triceps, fat overlying the ribs) 4. Muscle mass Moderate muscle loss (wasting of the clavicles, shoulders, scapula and calf) 5. Fluid accumulation Moderate top severe localized or generalized edema 6. Reduced grip strength Normative standards of the manufacturer Jane et al. Journal of Parenteral and Enteral Nutrition 2012; 36:

47 AA-CCM diagnostic tool Please apply it to the previous patient. An 85 year old female was admitted to the geriatric unit with pneumonia. She doesn t walk a lot but can get out of bed alone. She was found to have a pressure ulcer stage 2 in the coccygeal area. The patient is well oriented. Her height is 155cm and her weight is 50kg. She looks tired but not wasted. She used to be 55kg 3m ago. She has recently low appetite and is eating only one meal per day. HGS was of normal value.

48 Their objective was to provide a minimum set of criteria for the diagnosis of malnutrition to be applied independent of clinical setting and etiology, and to unify international terminology. Before diagnosis of malnutrition is considered it is mandatory to fulfill criteria for being at risk of malnutrition by any validated risk screening tool. Cederholm et al. Clinical Nutrition 2015; 34: ESEPN Concensus

49 ESPEN Diagnostic Criteria Two alternative ways to diagnose malnutrition. Alternative 1: BMI <18.5 kg/m2 Alternative 2: Weight loss (unintentional) > 10% indefinite of time, or >5% over the last 3 months combined with either BMI <20 kg/m2 if <70 years of age, or <22 kg/m2 if 70 years of age or FFMI <15 and 17 kg/m2 in women and men, respectively. Cederholm et al. Clinical Nutrition 2015; 34:

50 Comparison of Assessment Tools Adult Nutrition Support Core Curriculum, 3 rd edition, US: ASPEN.

51 Nutrition Diagnosis Many IDNT terms are related to malnutrition: Inadequate energy intake (NI-1.1) Inadequate oral intake (NI-2.1) Malnutrition (NI-5.2) Altered nutrition-related lab values (NC-2.2) Underweight (NC-3.1) Unintended weight loss (NC-3.2)

52 Medical Coding Medical coding: translating a diagnosis into a standardized medical code. ICD International Classification of Diseases 10 th revision have specified terms for malnutrition. ICD-11 is still under revision and has some improvements. This allowed for increased payment of care for patients whose dietitians and physicians diagnose with severe malnutrition.

53 Medical Coding E43: Unspecified severe protein-calorie malnutrition E44: Protein-calorie malnutrition of moderate and mild degree. E45: Retarded development following proteincalorie malnutrition E64: Sequel of protein-calorie malnutrition Academy of Nutrition and Dietetics, Nutrition Focused Physical Exam Pocket Guide, 2 nd edition.

54 But there is still to be done! There is a confusion of terminology. Malnutrition, protein-energy malnutrition, undernutrition, depletion, wasting, cachexia are some of the terms used to denominate the condition that ensues deficiencies of macro- and micronutrients and catabolism of protein and energy stores due to disease and ageing. But how to document simply clinically relevant malnutrition? Cederholm et al. Clinical Nutrition 2015; 34:

55 GLIM Criteria Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. A Two-Step Model for Risk Screening and Diagnosis Assessment Structured and easy to use Jensen et al. Journal of Parenteral and Enteral Nutrition 2018; September Epub

56 GLIM Criteria Requires at least 1 phenotypic criterion and 1 etiologic criterion for diagnosis of malnutrition. Jensen et al. Journal of Parenteral and Enteral Nutrition 2018; September Epub

57 GLIM Criteria Fat-free mass index using body composition methods such as bioelectrical impedance analysis, computed tomography, or magnetic resonance imaging. When not available, physical examination may be used. Hand-grip strength may be considered as a supportive measure. Jensen et al. Journal of Parenteral and Enteral Nutrition 2018; September Epub

58 GLIM Criteria Jensen et al. Journal of Parenteral and Enteral Nutrition 2018; September Epub

59 GLIM Criteria Jensen et al. Journal of Parenteral and Enteral Nutrition 2018; September Epub

60 Risk of malnutrition should have its own But there is still to be done! ICD Code! Malnutrition should be recognized as a serious clinical risk factor. In real clinical settings this is not the case, partly due to the lack of simple and unequivocal diagnostic criteria. It is crucial to reach consensus on diagnostic criteria for malnutrition in order to: Unify the terminology (e.g. for ICD-11) Enhance the legitimacy of nutritional practices Improve clinical care Cederholm et al. Clinical Nutrition 2015; 34:

61 Albumin Normal levels : g/dl and Half-life days Factors that decrease albumin: inflammation, liver failure, intravascular volume overload, zinc deficiency. Factors that increase albumin: intravascular volume depletion, steroids. Charney et al. ADA pocket guide to nutrition assessment

62 Prealbumin Compared with albumin, prealbumin has a shorter half-life and a smaller plasma pool (less affected by intravascular fluid volume). Negative acute-phase reactant It is a mores sensitive marker for recent dietary intake. It is not efficient to be used as sole criterion for malnutrition especially that it is affected by inflammation. Normal levels : mg/dl and Half-life 2-3 days Charney et al. ADA pocket guide to nutrition assessment

63 C-Reactive Protein CRP is used to monitor the presence, intensity, and recovery from an inflammatory process. Positive acute-phase reactant It is not useful as a nutritional marker. However, simultaneous levels of CRP can assist in determining whether inflammation has altered serum protein levels. Charney et al. ADA pocket guide to nutrition assessment

64 Other inflammatory markers that are confusing but should not be used as nutritional markers Transferrin: marker for iron transport with a halflife of 8-10 days. Sensitive to short-term changes in inflammation and affected by hydration Retinol-binding protein: binds to pre-albumin and marker for vitamin A transport Negative acute-phase reactant Also affected by vitamin A and Zinc deficiency and renal diseases Both lack sensitivity and specificity for malnutrition Adult Nutrition Support Core Curriculum, 3 rd edition, US: ASPEN.

65 Nutrition Risk for Critical Illness Nutrition Risk in Critically Ill NUTRIC score First tool validated specifically for ICU patients

66 NUTRIC Score, Mortality and Nutrition 1199 patients 28-day mortality Higher NUTRIC score associated with mortality. It should be used to identify critically ill patients most likely to benefit from optimal nutrition. Rahman et al. Clinical Nutrition 2016; 35 (1):

67 Nutrition Risk Screening in the ICU Subsample of fifty patients, admitted to ICU, candidates for Nutrition Support 84% Low High 77% 16% 23% NRS NUTRIC There was significant association between both scores used (p < 0.001). Ouaijan et al. Clinical Nutrition, 2016; ESEPN abstract book

68 Why is Malnutrition a relevant healthcare problem? Let s review relevant answers!

69 Clinical Implications of Malnutrition Impaired immune function More Infections Delayed wound healing Longer recovery from surgeries More risk for developing pressure ulcers Functional impairment Decreased muscle function Longer ventilation duration Norman et al. Clinical Nutrition 2008; 27: 5-15.

70 Implications of Malnutrition All these taken together, malnutrition is associated with: Increased Morbidity Increased LOS Increased Mortality Norman et al. Clinical Nutrition 2008; 27: 5-15.

71 Malnutrition and LOS P < 0.01 Days in Hospital Increased cost and economic burden on healthcare Allard et al. Clinical Nutrition 2016; 35:

72 Estimated financial cost implications of malnutrition Elia M. National Health Services NHS report 2015.

73 Estimated Financial Cost Implications of Malnutrition 741 millions 1.2 billion Euros 10% of National Health Expenditure Ljungqvist et al. Clinical Nutrition 2010; 29: Khalatbari-Soltani, S. Clinical Nutrition ESPEN, (3): p. e89-e94.

74 Does Malnutrition Matter in Healthcare?

75 Sir Dr Avid Wretlind said Do not ask if we should treat malnutrition but how we should!

76 Work in Team and Act Immediately! Screen Assess Intervene Simple Interventions can Improve Nutrition Care Adapted from ANHI

77 Nutrition Care Day Survey Large multicenter study reporting prevalence of malnutrition and poor food intake. SGA and 24-hour food recall 3122 patients: 32% malnourished 23% consumed < 25% of offered food Agarwal et al. Clinical Nutrition 2013; 32:

78 What is Beyond Assessment? Proper Nutrition Care Study in the UK where they implemented the following strategies: Nutrition nurse education module training covering nutrition screening and assessment. Weighing patient weekly. Change in catering practice from plated to bulk improving presentation, taste and texture of food. Better Hospital Food delivering snack boxes. Implementing a nutrition-screening tool. Referral system. O Flynn et al. Clinical Nutrition 2005; 24:

79 Reduction in prevalence of malnutrition by Nutrition Care 25.0% 23.5% 20.4% 19.1% P < % 15.0% % % 0.0% O Flynn et al. Clinical Nutrition 2005; 24:

80 Another Study: Nutrition Intervention Affects Directly LOS and thus Costs 14 days 11.5 days P < Malnourished - Control Malnourished - Intervention LOS Kruizenga et al. American Journal of Clinical Nutrition 2005; 82:

81 Nutritional Intervention Consisted of: Initial Screening Individualized nutritional assessment Dietetic consultation Oral Nutrition Supplementation ONS Enteral Nutrition when needed Kruizenga et al. American Journal of Clinical Nutrition 2005; 82:

82 Feed your Patients the Soonest Target them to the Right Patient at the Right Time!

83 Food Fortification Increasing the patient's nutritional intake by adapting their normal diet. Some tips to make the food more energy dense: Mix 1 cup of milk with 1/3 cup powdered milk. Add cheeses to the salad. Add nuts to the salad. Add roasted nuts to the rice when served. Add canned syrup to fruits. Add bread crusts to soups. Lochs et al. Clinical Nutrition 2006; 25 (2):

84 Oral Nutrition Supplements Supplementary oral intake of dietary food for special medical purposes in addition to the normal food. ONS are usually liquid but they are also available in other forms like powder, dessert-style or bars. If with 1200 kcal consumed of ONS patient meets all RDAs, then it is considered nutritionally complete and be used as sole source of nutrition. Lochs et al. Clinical Nutrition 2006; 25 (2):

85 ONS Effective and non-- invasive solution to tackling malnutrition in patients who are able to consume some normal food but not enough to meet nutritional requirements. They increase protein and energy intake without reducing spontaneous intake of food. Clinical benefits of ONS are often seen with: kcal/day (e.g. 1-3 ONS servings per day) 2-3 month s supplementation Supplementation periods may be shorter or longer. Stratton et al. Clinical Nutrition 2007; S2, 5-23.

86 ONS Studies have demonstrated that use of ONS is associated with: Weight gain Shorter LOS Reductions of mortality Improvements in quality of life and muscle strength Reductions in complications Stratton et al. Clinical Nutrition 2007; S2, 5-23.

87 ONS as part of Nutrition Care are Effective Study in surgical wards Smedley et al. British Journal of Surgery 2004; 91:

88 ONS as part of Nutrition Care are Costeffective 2,700 2,600 2,500 2,618 P < ,400 2,300 2,200 2,100 2,259 Mean cost per patient 2,000 Control ONS used Smedley et al. British Journal of Surgery 2004; 91:

89 Most Recent Meta-analysis To assess the effects of nutritional support on outcomes of medical inpatients with malnutrition or at risk for malnutrition in a systematic review of randomized clinical trials (RCTs 22 RCTs with a total of 3736 participants. Bally et al. Journal of the American Medical Association Internal Medicine 2016; 176:

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92 Caloric Debt is Associated with Worse Outcomes Total caloric deficit per week as compared to estimated day VFD ICU LOS Hosptal LOS Low (<6000Kcal) High (>6000Kcal) Dante et al.. Journal of Parenteral and Enteral Nutrition 2016; 40 (1):

93 Meeting Caloric Needs Decreases 60-day Mortality 167 intensive care units (ICUs) across 37 countries Alberda et al. Intensive Care Medicine 2009; 35:

94 What if a Dietitian is Involved in the ICU Team? 572 patients Baseline Dietitian + Protocol Baseline Dietitian + Protocol Kcal/kg delivered 0 Hospital LOS Soguel et al. Critical Care Medicine 2012; 40 (2):

95 What about Lebanon? In our ICU team: Enhanced multidisciplinary approach Implementation of standardized protocol 70% 60% 50% 40% 30% 20% 10% 50% 61% 63% 41% Baseline Intervention 0% Nutrition support started within 24hours Reaching caloric target within 72hours Ouaijan et al. ASPEN congress 2018.

96 hospital These small efforts will pay off at a large scale!

97 Reduction in National Prevalence of Malnutrition by Nutrition Care 25.0% 23.5% 20.4% 19.1% P < % 15.0% % % 0.0% O Flynn et al. Clinical Nutrition 2005; 24:

98 Nutrition Intervention Affects Increases Health Care Cost Savings Elia M. National Health Services NHS report 2015.

99 International Task Forces

100 Global Efforts are Joined to Fight Malnutrition Launched in 2014, the Optimal Nutritional Care for All (ONCA) campaign is a multi-stakeholder initiative to facilitate greater screening for risk of disease-related malnutrition/undernutrition and nutritional care implementation across Europe.

101 What about Lebanon? Difficulties in implementing interdisciplinary approach and referral system. Cost of nutritional support which is not covered neither by insurance nor by NSSF. They are paid Out-of-Pocket. A need for a national task force.

102 Our Initiative We are conducting a national study in Lebanon with the following objectives: Estimate prevalence of malnutrition at admission to Lebanese hospitals and at discharge. Validate a nutrition diagnostic tool that can be used in ICD Measure the impact of hospital malnutrition on health care costs. Recognize malnutrition as a serious clinical risk factor and develop national policies at the ministry level

103 Case Study: Head and Neck Cancer

104 Meet the patient J.K. is 50y.o. male previously healthy. He was first seen following a 2-year history of nasal stuffiness. He has smoked 2-packs of cigarettes per day for 30 years. He was treated intermittently with antibiotics and a decongestant without significant improvement. He developed numbness of the right cheek which caused him to seek treatment with an ENT. The patient also complained of headache, double-vision and hearing loss. CT showed an increase in soft tissue density within the nasal passages and right maxillary, sphenoid sinus and nasopharynx. CT of the neck showed evidence of bilateral cervical adenopathy with the largest node on the right side measuring 3 cm. Diagnosis Stage IV (advanced stage with metastasis) squamous cell carcinoma of the nasopharynx. Patient started concomitant chemotherapy and radiation therapy.

105 Head and Neck Cancer These cancers begin in the squamous cells that line the moist, mucosal surfaces inside the head and neck (for example, inside the mouth, the nose, and the throat). They are referred to as squamous cell carcinomas of the head and neck. Oral cavity: Includes the lips, the front two-thirds of the tongue, the gums, the lining inside the cheeks and lips. Pharynx: Excluding the esophagus Larynx Paranasal sinuses and nasal cavity Salivary glands: rare type of cancer From National Cancer Institute

106 Head and Neck Cancer From National Cancer Institute c

107 Meet the patient J.K. anthropometrics were taken. His height is 170cm and his weight is 73kg. He was surprised with his weight because 1 month ago he was 77kg. However J.K. has reported very low appetite due to some shortness of breath and dysgeusia (distortion of normal taste). He barely finishes his meals. In addition, he has been feeling tired and not being able to go to work on daily basis. His physical assessment looks normal but he has moderate fat wasting over the triceps.

108 Questions 1. What is the prevalence of malnutrition in head and neck cancer? 2. Use the MUST tool as screening tool on the J.K. 3. What is the best tool to be used for assessing malnutrition? Apply it on J.K.

109 Malnutrition and Head and Neck Cancer Prevalence: 50%. Many factors are associated with malnutrition: Metabolic effect of cancer Before treatment due to localized tumor effect: Obstruction of the digestive tract Hindering deglutition or mastication Side effect of treatment modalities From National Cancer Institute c

110 Malnutrition and Head and Neck Cancer Postsurgical changes may result in localized pain or difficulty with mastication and deglutition. Chemotherapy may induce mucositis, nausea, vomiting, stomatitis, fatigue, or neutropenia leading to infection that may contribute to a poor nutritional status. Radiotherapy can induce mucositis, xerostomia, change in viscosity of saliva, fistula formation, infection, fatigue, olfactory dysfunction that can significantly impair nutritional status. From National Cancer Institute c

111 PG-SGA Tool validated on cancer patients. Recommended by the Academy of Nutrition and Dietetics in head and neck cancer patients. Part is filled by the patient and the another part by a health care professional. Ottery adapted a self-administered questionnaire derived from the SGA for use by cancer patients, the PG-SGA (patient- generated SGA), the only tool specifically designed to assess malnutrition in oncology. This self-administered subjective global nutritional assessment is recommended as standard assessment in this type of population by the American Dietetic Association for the detection of malnourished subjects or at high risk of malnutrition. Prevost et al. European Annals of Otorhinolaryngology, Head and Neck diseases 2014; 131:

112 References Pirlich et al. Prevalence of malnutrition in hospitalized medical patients: Impact of underlying disease. Digestive Diseases 2003; 1: Norman et al. Prognostic impact of disease-related malnutrition. Clinical Nutrition 2008; 27: Ouaijan et al. Prevalence of malnutrition and the need for an efficient screening system in a hospital in Beirut. Clinical Nutrition 2013; 32 (S1): S231-S232. Allard et al. Decline in nutritional status is associated with prolonged length of stay in hospitalized patients admitted for 7 days or more: A prospective cohort study. Clinical Nutrition 2016; 35: Aoun et al. Prevalence of malnutrition in general surgical hospitals. The Lebanese Medical Journal 1993; 41: Elia M. The cost of malnutrition in England and potential cost savings from nutritional interventions. National Health Services NHS report Khalatbari-Soltani, S. and P. Marques-Vidal, The economic cost of hospital malnutrition in Europe; a narrative review. Clinical Nutrition ESPEN, (3): p. e89-e94.

113 References Compher at al. Diagnosing Malnutrition: Where are we and where do we need to go? Journal of the American Dietetic Association 2016; 116 (5): Butterworth CE Jr. Editorial: Malnutrition in the hospital. Journal of the American Medical Association 1974; 230 (6) :879. Ouaijan et al. Prediction of optimal nutrition support using the NUTRIC score and Identification of the common barriers to reach enteral nutrition target in an Intensive Care UNIT; ASPEN congress Ouaijan et al. Common barriers to reach enteral nutrition target in an Intensive Care Unit and the Use of the Nutrition Risk in Critically Ill (NUTRIC) Score to predict optimal Nutrition Support. Clinical Nutrition 2016; ESEPN abstract book. Mattar et al. Evaluation of Nutrition Support Practices: Results from the First National Survey in hospitals across Lebanon. Clinical Nutrition 2016; ESEPN abstract book. Modarski et al. Increased Knowledge, Self-Reported Comfort, and Malnutrition Diagnosis and Reimbursement as a Result of the Nutrition-Focused Physical Exam Hands-On Training Workshop. Journal of the Academy of Nutrition and Dietetics 2017; 117: Alberda et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Medicine 2009; 35:

114 References Ljungqvist et al. The European fight against malnutrition. Clinical Nutrition 2010; 29: O Flynn et al. The prevalence of malnutrition in hospitals can be reduced: Results from three consecutive cross-sectional studies. Clinical Nutrition 2005; 24: Kelly et al. Still hungry in hospital: identifying malnutrition in acute hospital admissions. QJM Monthly Journal of The Association of Physicians 2000; 93 (2): Fontes et al. Subjective Global Assessment: a reliable nutrition assessment tool to predict outcomes in critically ill patients. Clinical Nutrition 2014; 33 (2): Rahman et al. Identifying critically-ill patients who will benefit most from nutritional therapy: Further validation of the modified NUTRIC nutritional risk assessment tool. Clinical Nutrition 2016; 35 (1): Dante et al. Adequate Nutrition May Get You Home: Effect of Caloric/ Protein Deficits on the Discharge Destination of Critically Ill Surgical Patients. Journal of Parenteral and Enteral Nutrition 2016; 40 (1):

115 References Jane et al. Consensus statement: Academy of Nutrition and Dietetics and American Society of Parenteral and enteral Nutrition: Characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). Journal of Parenteral and Enteral Nutrition 2012; 36: Smedley et al. Randomized clinical trial of the effects of preoperative and postoperative oral nutrition supplements on clinical course and cost of care. British Journal of Surgery 2004; 91: Jensen et al. Adult starvation and disease-related malnutrition: A proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee. Clinical Nutrition 2010; 29: Kondrup et al. Nutritional Risk Screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clinical Nutrition 2003; 22: Matos et al. Handgrip strength as a hospital admission nutritional risk screening method. European Journal of Clinical Nutrition 2007; 61: Soguel et al. Energy deficit and length of hospital stay can be reduced by a twostep quality improvement of nutrition therapy: The intensive care unit dietitian can make the difference. Critical Care Medicine 2012; 40 (2):

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