Malnutrition: Where are we headed?

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1 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 kmogensen@bwh.harvard.edu

2 Disclosures I have no disclosures related to this topic

3 Objectives 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?

4 Kickin it Old School

5 JAMA 1936

6 Nutrition Today 1974

7 JPEN 1977 Issue 1!!

8 SGA!

9 Old Evaluation Parameters % IBW % UBW Presence of fat/muscle wasting Presence of edema Adequacy of intake Circulating proteins Anergy Other direct anthropometric measurements

10 Old Malnutrition Diagnoses Kwashiorkor Marasmus Mild, moderate, severe protein-calorie malnutrition Protein-calorie malnutrition, NOS Old Malnutrition Diagnoses

11 Blast from the Past! From ~ 1992!

12 BWH Old Criteria Severe PCM 3 # of Criteria Wt loss IBW wasting > 15% in 6 mo. Inadequate energy intake Albumin* < 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. *RDs trained not to use if inflammation or other confounder present

13 Malnutrition Outcomes: Old Characteristics CCM 2015 CCM 2015 JPEN epub 2016; print Feb 2017 JPEN epub 2016

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15

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18 Moving into modern times

19 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

20 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

21 Evaluation of Energy Intake Intake <75% of needs, no weight maintenance or gain Kondrup K. Clin Nutr. 2001

22 Weight Loss Evaluation

23 Physical Examination

24 Hand Grip Strength

25 Where are we headed? First stop: Validation!

26 Validation of the Academy/ASPEN Malnutrition Clinical Characteristics. Hand RK et al. JAND 2016

27 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: Hand RK et al. Validation of the Academy/ASPEN Malnutrition Clinical Characteristics. J Acad Nutr Diet 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

28 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

29 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

30 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

31 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

32 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

33 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

34 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

35 Comparisons to other markers

36 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

37 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

38 Validation, refining the characteristics, and more where do we go from here?

39 Functional Status and Outcomes CCM 2016 Surgery 2016

40 Functional Status and 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

41

42 Crit Care Med. 2016

43 Functional Status and 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?

44 Measures of Muscle Mass What are the roles of BIA CT Ultrasound Will these move into prime time?

45 Role of Metabolomics? Mogensen et al. JPEN 2017

46 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

47 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

48

49 Treatment of Malnourished Patients Is there a difference in clinical response in malnourished vs. well nourished patients? How do we study this?

50

51 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

52 Thank you!

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