Symposium 4 Food for Thought Challenging problems in Malnutrition

Transcription

1 Symposium 4 Food for Thought Challenging problems in Malnutrition

2 Malnutrition: a growing concern Dr John Puntis

3 Malnutrition in hospital definitions of malnutrition where have these come from? clinical surveys nutritional screening summary

4 Malnutrition in hospital the prevalence of malnutrition in paediatric hospitals ranges from 15%-30% of patients

5 Malnutrition in hospital the prevalence of malnutrition in paediatric hospitals ranges from 15%-30% of patients malnutrition among hospitalised children is often unrecognised and therefore not treated

6 Malnutrition in hospital malnutrition is bad for you the prevalence of malnutrition in paediatric hospitals ranges from 15%-30% of patients malnutrition among hospitalised children is often unrecognised and therefore not treated

7 Malnutrition in hospital impaired immune responses reduced muscle strength and fatigue reduced respiratory muscle strength impaired thermoregulation impaired wound healing impaired psycho-social function growth faltering

8 Malnutrition in hospital increased hospital stay increased costs justification for screening? evidence in the main from adult studies

9 Malnutrition in hospital how do we link nutritional status to outcomes in children? how much malnutrition is bad for you?

10 Malnutrition in hospital how do we link nutritional status to outcomes in children? how much malnutrition is bad for you? if we cant link malnutrition to outcomes, what point screening?

11 Malnutrition in hospital how do we link nutritional status to outcomes in children? how much malnutrition is bad for you? if we cant link malnutrition to outcomes, what point screening? however: a priori argument for preventing or reversing growth faltering

12 Malnutrition in hospital classification of malnutrition? do we all agree?

13 Malnutrition in hospital classification of malnutrition? do we all agree? problems of definition different types of malnutrition:

14 Malnutrition in hospital Malnutrition under nutrition, due to deficiency of nutrients over nutrition, due to an excess of nutrients micro-nutrients (trace elements and vitamins) macronutrients (protein, fat carbohydrate) clinical subclinical

15 Malnutrition in hospital Malnutrition under nutrition, due to deficiency of nutrients over nutrition, due to an excess of nutrients micro-nutrients (trace elements and vitamins) macronutrients (protein, fat carbohydrate) clinical subclinical some definitions.....

16 Malnutrition in hospital A continuum that starts with a nutrient intake inadequate to meet physiological requirements, followed by metabolic and functional alterations and in due course by changes in body composition.

17 Malnutrition in hospital A state of nutrition in which deficiency, excess or imbalance of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome.

18 Malnutrition in hospital form function clinical outcome

19 Malnutrition in hospital form function clinical outcome malnutrition is difficult to define

20 Malnutrition in hospital Most obvious and earliest signs of malnutrition in children: absence of normal weight gain weight loss visible decrease in fat; loss of muscle

21 Malnutrition in hospital Most obvious and earliest signs of malnutrition in children: absence of normal weight gain weight loss visible decrease in fat; loss of muscle malnutrition commonly defined in terms of anthropometry (arbitrary cut offs)

22 Malnutrition in hospital Gomez, Journal of Tropical Pediatrics, 1956 Mexico city; underfed children Boston growth standards 1st o weight 76-90% average for age 2nd o weight 61-75% average for age 3rd o weight <60% average for age higher death rate 3rd o v 2nd o (22.6% v 33.5%)

23 Malnutrition in hospital Gomez, Journal of Tropical Pediatrics, 1956 Mexico city; underfed children Boston growth standards 1st o weight 76-90% average for age 2nd o weight 61-75% average for age 3rd o weight <60% average for age higher death rate 3rd o v 2nd o (22.6% v 33.5%) link between nutritional status and outcome

24 Malnutrition in hospital Jelliffe, WHO Monograph 53, 1966 Assessment of the nutritional status of the community (with reference to field surveys in the developing world) ideally local reference population data age may not be known accurately defining nutritional status of a community

25 Malnutrition in hospital Waterlow, Lancet 1972 needs to be standard classification of PCM defining prevalence in different countries/communities purpose: planning prevention community: mild, moderate, severe severe cases: qualitative classification to distinguish marasmus, kwashiorkor and intermediate

26 Malnutrition in hospital 8th report of FAO/WHO Expert Cttee Nutrition height/length important reflects duration of malnutrition weight as percentage of expected weight for given height acute malnutrition height as percentage of expected height for age (where age available) chronic malnutrition

27 Waterlow, Lancet 1972

28 normal, and mild malnutrition Guide to action at a public health/community level

29 Malnutrition in hospital McLaren and Read, Lancet 1972 incorrect to assume that all children of same length should have the same weight relationship of weight with height varies with age

30 McLaren and Read WWC. Lancet 1972 Nomogram for categorising PCM

31 3 x as much moderate malnutrition!

32 Minor changes in arbitrary cut offs = large differences

33 WHO Classification classification moderate severe symmetrical oedema no yes weight for height -3SD - -2SD SD <-3 (<70%) (70-79%) (severe wasting) height for age -3SD - -2SD SD <-3 (<85%) (85-89%) (severe stunting)

34 Impact of using WHO growth standards Seal A. Institute of Child Health, London, 2008

35 Malnutrition in hospital Merritt RJ. Am J Clin Nutr 1979 Children s Hospital Medical Centre, Boston all patients > 3 mo Waterlow criteria acute malnutrition (wt for ht <90%) 36% chronic malnutrition (ht for age <95%) 47%

36 Malnutrition in hospital Moy RJD. J Hum Nutr Dietet 1990 Children s hospital, >3/12; NCHS; WHO acute malnutrition (wt for ht <-2SD) 14% chronic malnutrition (ht for age <-2SD) 16% scores SD = at risk from decreased intake, increased requirements, or losses 20% N.B. severe malnutrition mainly chronic disease

37 Malnutrition in hospital Hendrickse WH. Clin Nutr 1997 Children s hospital; acute malnutrition (wt for ht <5%) 16% (<-2SD 11%) chronic malnutrition (ht for age <5%) 15% (<-2SD 8%) at risk (-1-2 SD, ht +/- wt for age) 16%

38 Malnutrition in hospital Sermet-Gaudelus. Am J Clin Nutr 2000 Children s hospital; >1m % ideal body weight; French standards underweight 85-90%; mild undernutrition 80-84%; moderate 75-79%; severe <75% Malnutrition (PIBW <85%) 26% Waterlow: 80-90%; 70-80%; <70%

39 Malnutrition in hospital Pawellek I. Clin Nutr 2007 Children s Hospital; German standards; all admissions; Waterlow mild malnutrition (wt for ht 81-90%) 17.9% moderate malnutrition (70-80%) 4.4% severe malnutrition (<70%) 1.7% NB: greatest risk in complex patients (24.0%)

40 Malnutrition in hospital Joosten KF. Arch Dis Child 2010 national; paediatric units; >1m; Dutch standards; WHO criteria acute malnutrition (wt for ht <-2SD) 11% chronic malnutrition (ht for age <-2SD) 9% NB: 44% underlying chronic disease

41 Malnutrition in hospital What is nutritional screening? rapid, simple and general procedure used by nursing, medical or other staff, often at first contact with the patient, to detect those with significant risk of nutritional problems, so that clear guidelines for action can be implemented

42 Malnutrition in hospital Hulst JM. Clin Nutr 2010 Dutch STRONG kids nutrition screening score to prevent malnutrition along with its complications early identification of nutritional depletion is essential at risk of developing malnutrition: 62% median hospital stay 2 days for low risk, 3 days for high risk

43 Malnutrition in hospital What is being at nutritional risk?

44 Malnutrition in hospital What is being at nutritional risk? not the same as actually being malnourished

45 Malnutrition in hospital What is being at nutritional risk? not the same as actually being malnourished are screening tools good at predicting health outcomes related to nutritional status?

46 Malnutrition in hospital What is being at nutritional risk? not the same as actually being malnourished are screening tools good at predicting health outcomes related to nutritional status? requires thorough testing, because purpose is to change outcomes

47 Malnutrition in hospital What is being at nutritional risk? not the same as actually being malnourished are screening tools good at predicting health outcomes related to nutritional status? requires thorough testing, because purpose is to change outcomes how many children with mild malnutrition are thin? how many show catch up after an acute illness?

48 Malnutrition in hospital Are there other indicators of body form that might predict outcome?

49 Categories of BMI for identifying chronic proteinenergy malnutrition in adults BMI Weight Interpretation of status (kg/m 2 ) category <18.5 Underweight chronic under-nutrition probable Underweight chronic under-nutrition possible Desirable weight chronic under- or over-nutrition unlikely (low risk) Overweight increased risk of complications associated with overweight >30 Obesity risk of obesity related complications

50 arm circumference weight for age weight for height height for age Briend. Brit Med J Usefulness of nutritional indices and classification in predicting death of malnourished children. (Dhaka, n = 352)

51 Malnutrition in hospital What we don t have a shared understanding of what it means to be at risk a universally agreed definition of malnutrition a clear link between malnutrition and clinical outcomes a cogent argument for screening tools as opposed to universal nutritional assessment

52 Malnutrition in hospital Summary and conclusions definitions of malnutrition based on anthropometry will remain arbitrary until they are linked to clinical outcomes estimates of hospital malnutrition vary according to definitions used/reference data more recent use of WHO criteria give lower rates than in earlier studies

53 Malnutrition in hospital Summary and conclusions a priori case for avoiding or reversing growth failure growth monitoring (linked to action plans) should be routine for all patients

54 Malnutrition in hospital Jelliffe, WHO Monograph 53, 1966 Nutritional anthropometry: The interpretation of findings is always complex and often controversial even to leading authorities. The normal healthy wellfed human body can vary so much that interpretation of the nutritional significance of variations in physical dimensions is peculiarly difficult.

55 Common classification of protein energy malnutrition (children) Normal Mild Moderate Severe Weight for height* <75 Weight for age <60 Weight for age > <60 Height for age > <80 Weight for height > <70 presence of oedema = kwashiorkor; no oedema = marasmus * McLean 1975; Jelliffe1966; Gomez 1955; Waterlow 1972

56

57 Child Under-Nutrition in Affluent Societies: what are we talking about? Charlotte M Wright Ada Garcia School of Medicine, Glasgow University

58 How common is undernutrition? Prevalence varies from <1% to 12% Depends on measure used: Wt, Ht/Length, BMI, WFH, Centile falls, conditional SD change Threshold 2 nd, 3 rd, 5 th Growth reference used WHO/CDC 1978, CDC, WHO 2006, IOTF, UK 1990, French

59 What is under-nutrition? No gold standard test A net deficit of energy (and other nutrients) resulting in Loss of /failure to acquire fat stores Depending on severity /duration /age, may also cause Slow growth Low lean mass Metabolic derangement, immune suppression, catabolism

60 Wasting low BMI /WFH Assumed to reflect low fat Sound method to identify acute malnutrition when under-nutrition prevalence is high Little used in UK till recently Little known about clinical significance

61 Failure to thrive/ weight faltering More known about clinical significance Variability in how defined and understood Low weight for age over-identifies infants with low birth weight Centile falls over-identify initially large infants Conditional weight gain used for research purposes Primary care definition Fall through 2 centile spaces (3 if >91 st, 1if <9 th ) But prevalence varies with growth reference used

62 Mean (SE) Weight SDS Natural history of weight faltering 0 (slowest gaining 5% N=215) Intervention Whole cohort P=0.019 Intervention Controls Home visit P= Age in months

63 What causes weight faltering? Associated with relative undernutrition 2/3 show some evidence of low intake Low appetite, feeding behaviour differences No clear relationship (in UK) with deprivation 5% have other evidence of abuse or neglect Look for recovery with change of care 5-10% cases have symptoms or signs of underlying disease But if they look well they are well How many of the remaining 85% are truly undernourished?

64 So how common is true undernutrition in childhood? Concordance of weight faltering, wasting and stunting with fat levels in two population based cohorts Gateshead Millennium Study 860 subjects with anthropometry aged 1 year 600 with body composition measures aged 8 years ALSPAC 7,000 children with body composition measures aged 7-11 ILLENNIUM BABY STUDY

65 Concurrence of different definitions in GMS cohort Wasting <2nd centile for BMI (UK 1990) Sustained weight faltering <5th internal centile for conditional weight gain since birth at 2 or more ages 4.1% (35) 1.8% 3.8% (32) (15) 0.4% (3) Stunting <2nd centile for length (UK 1990) 0.6% (5) 0.1% (1) True undernutrition? Prevalence = 2.3%

66 Z score How different measures of undernutrition in infancy relate to growth and body composition outcomes aged 8 years BMI<2nd only (35) Weight faltering only (32) WF plus low BMI or stunting (19) Wasted = low average fat and lean mass Weight faltering = low average height but proportionate to parents Weight BMI Adiposity Lean (BIA) Height Mid parental height

67 Z score How different measures of undernutrition in infancy relate to growth and body composition outcomes aged 8 years BMI<2nd only (35) Weight faltering only (32) WF plus low BMI or stunting (19) Weight faltering+ = low fat and lean mass Short and shorter than parents Weight BMI Adiposity Lean (BIA) Height Mid parental height

68 79% of those with BMI below 2 nd centile were above fat 5 th centile 79% of those <BMI 2 nd, were >fat 5 th centile Does a low BMI in childhood? actually reflect low reserves 46% above 95th have high fat ALSPAC study Ages 7-11 years 52% of those with BMI below 2 nd were 52% below of those lean <BMI 5 th 2 nd, centile were <lean 5 th centile 19% <2nd have low fat

69 Concurrence of low BMI and fall in BMI with low body fat in ALSPAC, aged eleven Wasting <2nd centile for BMI (UK 1990) 1.0% (62) 0.74% (44) 0.12% (7) 0.08% (5) Low fat <5th internal centile for fat (BIA) adjusted for height, age, gender 4.9% (291) 4.0% (237) 0.18% (11) True undernutrition? Prevalence = 1.12% BMI SD change <5th internal centile

70 Concurrence of low BMI and fall in BMI with low body fat in ALSPAC, aged eleven Wasting <2nd centile for BMI (UK 1990) 1.0% (62) 0.74% (44) 0.12% (7) 0.08% (5) Low fat <5th internal centile for fat (BIA) adjusted for height, age, gender 4.9% (291) 4.0% (237) 0.18% (11) True undernutrition? Prevalence = 0.38% BMI SD change <5th internal centile

71 How should under-nutrition be diagnosed? Sceptically, without relying on a single measure Weight trajectory BMI Skinfolds (DXA / BIA) Response to treatment Functional assessment

72 Undernutrition in childhood in the UK Still present in 2% infants, <1% children Many screen positive cases are not undernourished at all Most of rest are only mildly undernourished Assess sensitively Treat proportionately A few will have organic disease or be suffering neglect Look for supporting evidence Not a diagnosis by exclusion

73 My thanks to: All involved with Gateshead Millennium and ALSPAC studies Funders Henry Smith Charity SPort Aiding Research in KidS Newcastle, North Tyneside and Northumberland NHS R&D Scottish Chief Scientists Office NPRI British Heart Foundation

74 WHO 2006 standard describes how all children <5 years should grow

75 Impact of new WHO standard Reduces prevalence of low weight, BMI or WFH compared to earlier standards But increases prevalence of wasting <6m WHO estimates of prevalence in affluent countries Low weight for age (-2SD) 1.6% Stunting (height for age <-2SD) 6% BMI /WFH from single studies (UK, USA) 4m 2 % 8m onwards <1%

76 Concurrence of wasting and stunting with low body fat in ALSPAC aged Seven Wasting <2nd centile for BMI (UK 1990) 0.9% (68) 0.26% 20 Low fat <5th internal centile for fat (BIA) adjusted for height, age, gender 0.07% (6) 4.7% (364) 1% (81) 0.03% (2) Stunting <2nd centile for length (UK 1990)

77 Concurrence of low BMI, fall in BMI and stunting with low body fat in ALSPAC aged eleven Wasting <2nd centile for BMI (UK 1990) 1.5% (108) 0.37% (27) Low fat <5th internal centile for fat (BIA) adjusted for height, age, gender 4.6% (335) 0.1% (7) 0.62% (45) 0.01% (1) 0.03% (2) Stunting <2nd centile for length (UK 1990)

78

79 Roswyn Hakesley-Brown CBE MPhil, BA, RN Chair, The Patients Association

80

81 The Prevalence of Malnutrition in General Practice Paula McGurk PhD RD Research Dietitian University Hospital Southampton NHS Foundation Trust Professor Marinos Elia Dr Abbie Cawood Dr Rebecca Stratton

82 Distribution of Malnutrition in the UK according to Care Setting ~2% hospital ~5% care homes ~93% community (2-3% sheltered accommodation) (Elia & Russell, 2009)

83 Prevalence of Malnutrition in General Practice (GP) Few reports (Edington et al 1996; Martyn et al 1998; Turnbull & Sinclair 2002) Often reported in specific patient groups and populations, e.g. malnutrition in cancer patients Inconsistency in patient selection procedures and methods of identifying malnutrition No reports of large series involving patients consecutively visiting their GP, screened using consistent criteria, such as those in MUST

84 Aims 1. a) What is the prevalence of malnutrition in people visiting their GP and to what extent is it identified and treated? b) How representative is the study population of the general population in England? 2. Is malnutrition related to health outcomes and healthcare use? k

85 Methods Developed a questionnaire General characteristics Age, gender, GP Postcode Attended a *Health Practice Outcomes Manager forum Unhealed wounds, Infections, Weight loss *Healthcare use GP visits Antibiotic use 6 General Practices agreed to host *In the previous 6 months Visited surgeries (Nov 10- May 11)

86 Methods Weight, Height and Weight loss (used data to apply MUST criteria) Rank of Index of Multiple Deprivation Score established using GP postcode (1 (most deprived) - 32,482 (least deprived) ) (Nobel et al 2011) Health outcomes & healthcare use: Questionnaire

87 Results 1a: Patients 970 invited to participate 601 (62%) screened 369 (38%) did not participate 146 were relatives/carers/ friends 455 were attending for an appointment Variable Mean SD BMI (kg/m 2 ) Weight (kg) 26.3 ± ±17.1 Age (yrs) 41.8 ±18.3

88 Results 1a: Medium and High risk patients (n 455) % % 6.2% MUST category High risk Medium risk 10.8%

89 Results 1a: Prevalence of Malnutrition (M+H risk) (n 455) Overall prevalence 10.8% (95% CI 8.2% 14.0%) 8.7% Step 1; BMI contribution to MUST: 39 / 455 (8.7%) BMI Wt loss 7.8% 0.9% 2.1% Step 2; Weight loss contribution to MUST: 14 /455 (3%) Step 3 Acute disease score effect; No contribution 3%

90 1.b: Rank of Index of Multiple Deprivation Score LEAST DEPRIVED 32,482 Average in England (16,241) General Practice ( ; mean 8138) 1 MOST DEPRIVED

91 % of population Results 2: Health Outcomes and Healthcare use (last 6 months) P= % 60.6% 40 Significant difference (P<0.05) P= % Low risk Med & High risk % 8.2% 0 2.2% Unhealed wounds Infections requiring Abx 1 GP visit in last 6 months

92 Discussion and conclusion 1. a) Prevalence of malnutrition in those attending the GP is 10.8% (95% CI 8.2%, 14.0%), all of which was unrecognised and untreated. b) All practices were located in areas of higher deprivation (caution in generalisations) 2. Current malnutrition tended to be associated with adverse health outcomes and increased healthcare use during previous 6 months.

93 References Elia M (Editor) 2003 The MUST report. BAPEN, Redditch. Elia M & Russell C.A (2009) Combating Malnutrition: Recommendations for Action. Nobel et al (2011) Indices of Deprivation 2010 for Super Output Areas (

94