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Joanna Hopkins
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2 Etiology driven approach to malnutrition diagnosis Supporting systematic approach to nutrition assessment. Affordable Care Act - opportunities Conclusions Where do we go from here? The speaker has no disclosures relevant to this presentation.

4 Historic Famine / starvation were prevalent Today Famine / starvation still occur War and genocide, food deprivation as weapon Malnutrition in setting of disease or injury now very prevalent

5 Refugees and Displaced Populations Leaning J, Guha-Sapir D. N Engl J Med 2013;369:

6 Both patients are under-nourished

7 Diagnostic criteria lack full validity. Poor specificity, sensitivity, and interobserver reliability. Overlapping definitions and misdiagnosis. Multiple definitions resulting in widespread confusion. Lack modern appreciation for role of inflammatory response.

9 Corkins MR, et al. JPEN, Epub. Nov. 18, HCUP 2010 registry of hospital discharges. Examined ICD-9 malnutrition diagnoses. 3.2% of discharges had a malnutrition (under-nutrition) diagnosis. Those with a malnutrition diagnosis were older, had longer lengths of stay, and incurred higher costs. They were also more likely to have comorbidity, be discharged to home care, and suffer mortality.

10 Patients coded as malnourished may or may not have actually been malnourished. Many malnourished patients were likely not diagnosed as such. The adverse outcomes associated with a malnutrition diagnoses may well have been caused by other covariates. While 13.4% of the patients who received a malnutrition diagnosis received either PN or EN, it is not possible to address benefit.

11 Pathophysiology of malnutrition that is associated with disease or injury invariably consists of a combination of varying degrees of under- or over-nutrition and acute or chronic inflammation, leading to altered body composition and diminished biological function. Disease-related malnutrition the point at which the severity or persistence of inflammation results in a decrease in lean body mass associated with functional impairment. Soeters P, Clin Nutr 27: (2008). Jensen GL, et al, Clin Nutr 29: (2010) and JPEN 34: (2010).

12 Anorexia Decreased nutrient intake Altered metabolism Elevation of resting energy expenditure Muscle catabolism - increased nitrogen excretion Micronutrient status Iron, Zinc, Selenium, Vitamin D, Vitamin A, and others Blunts response to nutrition interventions

13 Starvation-related malnutrition Chronic starvation without inflammation anything that limits access to food; for example anorexia nervosa Chronic disease-related malnutrition Inflammation is chronic and of mild to moderate degree organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity Acute disease or injury-related malnutrition Inflammation is acute and of severe degree major infection, burns, trauma or closed head injury

15 Proposed approach Malnutrition in the context of acute illness or injury Malnutrition in the context of chronic illness Malnutrition in the context of social or environmental circumstances Criteria energy intake, weight loss, physical findings (SQ fat, muscle mass, fluid retention, and reduced grip strength J Acad Nutr Diet. 2012;112(5):

16 Malnutrition Level Moderate Severe Illness/Injury Acute Chronic Social/Env Acute Chronic Social/Env Food Intake (% Usual), Duration Weight Loss (% Usual), Duration <75% >7d <75% >30 d <75% >90 d <50% >5d <75% >30d 1-2%, 1 week >2%, 1 week 5%, 1 month >5%, 1 month <50% >30d 7.5%, 3 months >7.5%, 3 months 10%, 6 months >10%, 6 months 20%, 1 year >20%, 1 year Fat Loss Mild Moderate Severe Severe Muscle Loss Mild Moderate Severe Severe Edema Mild Moderate Severe Severe Grip Strength Not Applicable Reduced Severe

17 History and clinical diagnosis Clinical signs / physical exam Anthropometric data Laboratory indicators Dietary assessment Functional outcomes JPEN 2012;36: and ASPEN Adult Nutrition Support Core Curriculum. 3 rd edition, 2012.

18 Weight history >10% weight loss associated adverse outcomes Medical records, family, and caregivers Medical / surgical history Recognize conditions or disease that are associated with inflammatory response Recognize conditions or disease that place one at nutritional risk Medication history

Nonspecific clinical indicators of inflammation may include fever, hypothermia or tachycardia. Note physical findings of weight loss. Marked edema may mask weight loss.

19 Nonspecific clinical indicators of inflammation may include fever, hypothermia or tachycardia. Note physical findings of weight loss. Marked edema may mask weight loss. Examine of parts of the body where high cell turnover occurs (e.g. hair, skin, mouth, tongue) as they are among the most likely to exhibit specific signs of nutritional deficiencies.

Body weight Measure to monitor weight change trends Reliance on self-reported weights or other sources of data may be unreliable Height Measure in standing position if possible Height

23 Body weight Measure to monitor weight change trends Reliance on self-reported weights or other sources of data may be unreliable Height Measure in standing position if possible Height can be roughly estimated by doubling the arm span measurement (from the patient s sternal notch to the end of the longest finger). Height in older persons can be estimated from knee height

24 Weight standardized for height Reference tables ideal body weight limited by subjective interpretation of frame size and inadequate reference data for may population groups. Body mass index (BMI, kg/m 2 ) practical measure of body size and indirect measure of body fatness.

Skin-folds and circumferences Reliable measurements require training so they have had limited practical application NHANES III Anthropometric Procedures Video Other body composition tools BIA, DEXA,

25 Skin-folds and circumferences Reliable measurements require training so they have had limited practical application NHANES III Anthropometric Procedures Video Other body composition tools BIA, DEXA, CT, and MRI portability issues for all except BIA May be possible to take advantage of CT or MRI studies that are being done for other clinical purposes to evaluate musculature Baracos VE, AJCN 2010; 91: 1133S-1137S.

26 No single laboratory test or panel that allows one to diagnose a malnutrition syndrome, so laboratory findings must be appropriately used in combination with other assessments. Albumin and prealbumin are reduced by the acute systemic inflammatory response to injury, disease or inflammation. C-reactive protein is a positive acute phase reactant that can be measured to help discern whether active inflammation is present. Cytokines and in particular interleukin-6 have also demonstrated potential as indicators of inflammatory status.

27 Nonspecific indicators that may suggest inflammatory response include leukocytosis and hyperglycemia. Further tests include 24-hour urine urea nitrogen and indirect calorimetry. Negative nitrogen balance and elevated resting energy expenditure are anticipated in severe acute systemic inflammatory response.

28 Modified diet history If necessary, information can be obtained from medical records, family, and caregivers. Dietary practices and use of nutrition supplements should also be noted. Since patients will often present with acute events superimposed upon significant chronic health conditions, it is not unusual for patients to have had compromised dietary intakes and malnutrition for extended periods prior to admission.

29 Nutrition support Monitor how much of the requested nutrition is actually being administered to and received by the patient. Enteral feedings in particular are frequently interrupted or held for procedures, tolerance issues, feeding tube displacements, and other events. With transition to oral intake it is important to monitor amounts of food and / or supplements consumed as well as patient tolerance. Anorexia is commonly associated with ongoing inflammatory response.

Advanced malnutrition syndromes are associated with loss of muscle mass and function that result in measureable declines in strength and performance.

30 Advanced malnutrition syndromes are associated with loss of muscle mass and function that result in measureable declines in strength and performance. Hand-grip strength Physical performance batteries Malnutrition also results in impaired respiratory muscle function and compromised wound healing. Other potential outcomes cognitive, physiologic, and molecular

31 Pilot at 3 Cleveland hospitals with 10 RD s and 20 patients per site. Clinical characteristics, laboratories, vital signs, infections, QOL, and SGA. Academy of Nutrition and Dietetics Health Informatics Infrastructure data collection tool. Outcomes length of stay, falls, pressure wounds, infections, readmissions, ED visits, death, and DRGs. Full study 600 patients, multi-site Training in nutrition-focused physical exam at Cleveland Clinic

32 Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN 2013;37: In the developed world, malnutrition is predominately related to disease, chronic conditions, trauma, burns or surgery. Incorporate recognition of an inflammatory component.

33 Figure 1. Defining malnutrition in hospitalized children: Key concepts. Mehta N M et al. JPEN J Parenter Enteral Nutr 2013;37: Copyright by The American Society for Parenteral and Enteral Nutrition

34 Gut injury Inflammatory bowel disease Pancreatitis Periodontal disease Wounds / trauma Sepsis / ARDS Aging Arthritis HIV / AIDS Asthma COPD Organ failure Heart Lung Liver Kidney Obesity Metabolic syndrome Cardiovascular disease Diabetes Destructive joint disease Cancer If your favorite disease is not here, it probably will be soon!!

35 Specialized nutrition support, anti-inflammatory diets, glycemic control, physical activity, appetite stimulants, anabolic agents, anti-inflammatory agents, anti-cytokines, probiotics Decreased Inflammation Poor outcome Recovery Multi-faceted approach

36 Multiple approaches to characterizing malnutrition. We must work towards consensus. Laboratory, functional, food intake or body weight criteria in support of these approaches will require further testing. Priority for better indicators - Omics research has potential to help discern inflammatory risk and to monitor response to therapies. Translation of new diagnostic approaches to routine clinical practice will require validation. New approaches to assessment and diagnosis are a work in progress.

37 Incentives to improve patient care and outcomes Early hospital readmission penalties for acute MI, heart failure, and pneumonia Medicare Potential for expansion of medical nutrition therapy coverage beyond renal and diabetes care. Annual wellness visit with personalized prevention plan services.

38 Employee wellness Medicare / Medicaid preventive services Medical homes Home health Personalized medicine School-based clinics Childhood obesity Nutrition labeling Breast feeding

39 Affordable Care Act requires chain restaurants with more than 20 locations to display calorie information on their menus Block JP, Roberto CA. JAMA 2014; 312: Affordable Care Act requires employers to provide reasonable break time and a place for nursing mothers to express breast milk. Raju TNK. Pediatrics 2014; 134:

Post-Hospital Syndrome an acquired, transient condition of generalized risk. Krumholz HM. NEJM 2013; 368:100-102.

40 Post-Hospital Syndrome an acquired, transient condition of generalized risk. Krumholz HM. NEJM 2013; 368: Predicting early non-elective readmission in nutritionally compromised adults. Friedmann JM, Jensen GL, Smiciklas-Wright H, McCamish MA. Am J Clin Nutr 1997; 65:

41 Tuma PA. An overview of the intentions of healthcare reform. J Acad Nutr Diet 2012; 112(suppl 1): Rosen BS, Maddox PJ, Ray N. A position paper on how cost and quality reforms are changing healthcare in America: focus on nutrition. J Parenter Enteral Nutr 2013; 37:

Etiology based definitions for adult malnutrition: Role of inflammation A systematic approach to nutrition assessment

Etiology based definitions for adult malnutrition: Role of inflammation A systematic approach to nutrition assessment Gordon L Jensen, MD, PhD Penn State University University Park, PA Objectives Review