Malnutrition and
Nutrition Focused
Physical Exam
Trudi Coleman MS RD LDN
Annelise Chmelik RD LDN
Clinical Dietitians at Ingalls Memorial Hospital
Disclosures
• None
Learning Objectives:
• Identify and apply AND/ASPEN Criteria to diagnose and
document adult malnutrition in the clinical setting
• Understand the role of inflammation in malnutrition
• Identify severity of muscle atrophy, subcutaneous fat loss, and
nutrition related edema
• Discuss a malnutrition case study
Malnutrition
Overview
Malnutrition Definitions:
Simply put, malnutrition can be defined as “any
nutritional imbalance”
“decline in lean body mass with the potential for
functional impairment” – Dr. Gordon Jensen
Malnutrition
• 1 in 3 patients are malnourished
• Approximately one third of patients who are not malnourished on
admission to hospitals may become malnourished while
hospitalized
• Patients diagnosed with malnutrition have a length of stay 3 times
longer
• Patients with malnutrition are more likely to develop pressure
ulcers, surgical site infections, intravascular device infections, and
catheter-associated urinary tract infections
• The annual burden of disease-associated malnutrition across 8
diseases in the U.S. is $156.7 billion
JPEN J Parenter Enteral Nutr. 2014;38(S2):77S-85S.
JPEN J Parenter Enteral Nutr. 2013;37:482-497.
Int J Environ Res Public Health. 2011;8:514-527.
Etiology-Based Malnutrition
Definitions
In 2009, ASPEN & ESPEN convened an International Consensus
Guideline Committee to develop an etiology-based approach to
the diagnosis of adult malnutrition based on the severity of
inflammation.
• Starvation-Related (without inflammation)
• Chronic-Disease-Related (mild to moderate inflammation)
• Acute-Disease Related (severe inflammation)
Jensen GL, et al, JPEN 2010; 34(2):156-159
Etiology-Based Malnutrition Definitions
JPEN. 2009;33(6):710-716.
Common Diagnoses Associated with the
Etiologies of Malnutrition
Acute Illness
Abdominal abscess
ARDS
Burns
Cellulitis
Closed Head Injury
Trauma
Major infection / Sepsis
Major surgery
Chronic Illness
Organ failure
Cancer
Cardiovascular disease
Celiac disease
Congestive heart failure
Cystic fibrosis
Cerebrovascular accident
Chronic pancreatitis
Diabetes
HIV
Inflammatory Bowel Disease
Lupus
Obesity
Pancreatic pseudocyst
Rheumatoid arthritis
Social or Environmental
Circumstances
Alcoholism
Dementia
Drug abuse
Eating disorders
Economic hardship
Mental disorders
Inflammation
• A protective tissue response to injury or destruction of tissues,
which serves to destroy, dilute, or wall off both the injurious
agent and the injured tissues
• Increased concentrations of inflammatory mediators in which
there may be signs of swelling, erythema, hypothermia,
hyperthermia, and pain
Acute Inflammation
Chronic Inflammation
Fever (>= 99.9 F)
Swelling
Erythema
Hypothermia (<95 F)
Hyperglycemia
Elevated BP
Elevated CRP
Leukocytosis
Tachycardia (HR > 100
beats/min)
Lack of classic signs of
inflammation
Minor elevation of CRP
Purpose: defense, repair
Purpose: maintain homeostasis
Jensen GL, ASPEN Adult Core Curriculum, 3rd edition 2012
Why is inflammation important?
Inflammation increases the risk for malnutrition
and may contribute to suboptimal response to
nutrition intervention, and therefore, increases
risk for mortality.
JPEN. 2006:30(5)453-463.
Inflammatory Biochemical Markers
• Laboratory indicators of inflammation can include C-reactive
protein (CRP), white blood cell count, and blood glucose levels
• Negative nitrogen balance and elevated resting energy
expenditure may sometimes be used to support the presence
of systemic inflammatory response
• Negative acute phase proteins (albumin, prealbumin) do not
consistently or predictably change in response to changes in
weight, nutrient intake, or nitrogen balance – therefore,
inflammatory markers are currently not recommended for
use as malnutrition diagnostic criteria
JPEN. 2006:30(5)453-463.
Academy of Nutrition and Dietetics Evidence Analysis Library. Accessed 5/23/17.
Imaging studies that can support the presence
of inflammation:
Imaging Study
Condition
Chest x-ray or CT
Pneumonia, infiltrates
Abdominal x-ray or CT
Abscess, pancreatitis, bowel
obstruction, hepatitis
Esophagogastroduodenoscopy (EGD)
Colonoscopy
Gastritis, esophagitis, Crohn’s, ulcerative
colitis, radiation enteritis, strictures
Transesophageal echo (TEE)
Endocarditis, congestive heart failure
The AND/ASPEN Consensus Statement (2012)
• In May 2012, AND/ASPEN published the Consensus Statement for identifying and
documenting adult malnutrition
• Malnutrition is most simply defined as any nutritional imbalance
• Adult undernutrition typically occurs along a continuum of inadequate intake
and/or increased requirements, impaired absorption, altered transport and
altered nutrient utilization
• “Malnutrition is a major contributor to increased morbidity and mortality,
decreased function and quality of life, increased frequency and length of hospital
stay and higher healthcare costs.”
• Current estimates of the prevalence of adult malnutrition range from 15% to
60% depending on the patient population and criteria used to identify its
occurrence
• Only about 3% of patients admitted to acute care settings in the U.S. are
diagnosed with malnutrition
White et al, JPEN, 2012 Consensus Statement
6 Characteristics to Identify and
Document Malnutrition:
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Insufficient energy intake
Unintentional weight loss
Loss of body fat
Loss of muscle mass
Fluid accumulation
Diminished functional capacity
**2 or more recommended for diagnosis
White et al, JPEN, 2012 Consensus Statement
Characteristics of Non-Severe Malnutrition
Minimum of 2 characteristics needed for diagnosis
Acute Illness or
Injury
Chronic Illness or
Disease
Environmental or
Social Circumstance
(Starvation)
Reduced Dietary
Intake
>7d intake
<75% total EER
≥ 1 mo intake
<75% total EER
≥ 3 mo intake
<75% total EER
Unintended Weight
Loss
1-2% in 1 wk
5% in 1 mo
7.5% in 3 mo
5% in 1 mo
7.5% in 3 mo
10% in 6 mo
20% in 1 yr
>5% in 1 mo
>7.5% in 3 mo
>10% in 6 mo
>20% in 1 yr
Loss of
Subcutaneous Fat
Mild Loss
Mild Loss
Mild Loss
Muscle Loss
Mild Loss
Mild Loss
Mild Loss
Fluid accumulation
Mild Edema
Mild Edema
Mild Edema
Reduced Grip
Strength
N/A
N/A
N/A
White et al. JPEN, 2012 Consensus Statement
Characteristics of Severe Malnutrition
Minimum of 2 characteristics needed for diagnosis
Acute Illness or
Injury
Chronic Illness or
Disease
Environmental or
Social Circumstance
(Starvation)
Reduced Dietary
Intake
≥5d intake
≤50% total EER
≥1 mo intake
≤75% total EER
≥1 mo intake
<50% total EER
Unintended Weight
Loss
>2% in 1 wk
>5% in 1 mo
>7.5% in 3 mo
<5% in 1 mo
>7.5% in 3 mo
>10% in 6 mo
>20% in 1 yr
>5% in 1 mo
>7.5% in 3 mo
>10% in 6 mo
>20% in 1 yr
Loss of
Subcutaneous Fat
Moderate Loss
Severe Loss
Severe Loss
Muscle Loss
Moderate Loss
Severe Loss
Severe Loss
Fluid Accumulation
Moderate to Severe
Edema
Severe Edema
Severe Edema
Reduced Grip
Strength
Measurably Reduced
Measurably Reduced
Measurably Reduced
White et al. JPEN, 2012 Consensus Statement
Coding for Malnutrition
ICD-10 Codes
• E43: Unspecified severe protein-calorie
malnutrition
• E44.0: Moderate protein-calorie malnutrition
• E44.1: Mild protein-calorie malnutrition
• E45 Retarded development following
protein-calorie malnutrition
• E46: Unspecified protein-calorie malnutrition
• E64.0: Sequelae of protein-calorie
malnutrition
Performing a NutritionFocused Physical Exam
Getting Started
Prior to patient interaction:
Review the electronic medical record
• Physician dictations
• Nursing notes
• Food intake
• Weight history
Collaboration with healthcare team
In the patient room:
Introduce yourself
Ask questions related to health and
nutrition history
Explain what you would like to do and
obtain patient permission to perform
NFPE
Prepare your script
Wash hands, put on gloves, and
ensure privacy
Tools
• Eyes
• Hands
• Gloves
Position patient and explain what you
are doing as you complete NFPE
Thank patient for their time
Basic NFPE Exam Techniques
• Inspection
Broad observation of color, shape, texture, size. Involves senses of
sight, smell and hearing.
• Palpation
Examining body structures using touch (assess texture, size, temp,
tenderness, mobility)
• Advanced Techniques:
Percussion
Auscultation
Physical Characteristics to Note
During Interview
Body habitus- physique or body type
• Ectomorphic: underweight
• Mesomorphic: normal weight
• Endomorphic: overweight or obese
Assessing Fat and Muscle Loss
Areas of Subcutaneous
Fat Loss
• Orbital fat pads
• Triceps
• Thoracic & Lumbar
region
Areas of Muscle Loss
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•
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Temples
Shoulders
Clavicles
Scapular region
Hands
Quadriceps
Gastrocnemius
Subcutaneous Fat Loss
Orbital
Triceps
Ribs & Chest
Subcutaneous Fat Loss
Subcutaneous fat loss is determined by:
• Assess fat “pads” under skin
• Assess “pillows” over bony prominences
• Observe loose or hanging skin
• Observe if bones are prominent
• Determine pinch depth  “bread dough”
Orbital Fat Pads
Examine the eye socket area
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•
•
View patient when standing directly in front of them.
Palpate the fat pads above the cheekbone
Inspect for loss of bulge under eye
Loose or saggy skin, dark circles, hollowing
 Normal: bouncy to slightly bulged fat pad
 Mild-Moderate: slightly dark circles, somewhat hollow
 Severe: pronounced, hollow, depressed, dark circles, loose
skin
Orbital Fat Pads
Periorbital Edema
• Fluid collection or
“puffiness” around eyes
• Causes:
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•
•
•
•
•
•
•
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Fluid retention
CHF
Renal failure
Nephrotic syndrome
Hypoalbuminemia
Allergies
Steroid use
Periorbital cellulitis
Myxedema
Patient with bilateral thyroid eye
disease
Triceps
Examine the upper arm region
• Arm is bent at 90 degree angle
• Assessing pinch depth (fat loss)
• Pinch and roll skin over the triceps muscle between thumb and
forefinger
• Be sure to not have muscle in pinch
 Normal: ample fat tissue (about 1 inch) when pinched
 Mild-Moderate: some depth to pinch, fingers almost touch
 Severe: very little space between folds, fingers touching
Triceps
Thoracic/Lumbar Region
Examine the ribs, lower back, and midaxillary line at the iliac
crest
• Have patient sit up with hands stretched out in front while
pressing hands against a solid object
• Assess for fat loss between ribs and at the lower back
 Normal: ample fat tissue, chest is full and the ribs should
not be visible
 Mild-Moderate: loose skin, ribs are apparent, some fat
can be pinched at the iliac crest
 Severe: skin is stretched, deep depressions between ribs;
prominent, well-defined ribs; minimal to no fat can be
pinched at the iliac crest
Thoracic/Lumbar Region
Bilateral Muscle Wasting
Bilateral Muscle Wasting
Muscle wasting is determined by:
• Palpation for bulk and tone
• Depressions, flat or hollow areas, “squared-off” appearance
• Prominent or protruding bone
Keep in mind:
• The upper body is more susceptible to muscle atrophy first
and has been identified as a good reflection of overall
muscle mass
• Muscle loss from inactivity or immobility is most prominent
in the pelvis and legs
Temporal Region
Examine the temporalis muscle
• Observe patient straight on
• Look for prominence of brow bone, scooping or hollowing
• Palpate with a scooping motion- vertically, horizontally, and
diagonally
• Assess for tone and thinning of muscle
• Well-developed temporalis muscle  taut, leather belt
• Temporalis muscle wasting  watery, flaccid water balloon, condiment
packet
 Normal: well-defined muscle
 Mild-Moderate: slight depression
 Severe: hollowing, scooping depression
Temporal Region
Pectoralis Muscle
Examine the clavicle bone and pectoralis muscle
• Have the patient sit upright and not hunched over
• Look for prominent protrusion of bone
•
Women: clavicle is naturally visible
• Assess the muscle tone below the clavicle
• Palpate in a scooping motion – fingers should not slide under the
clavicle
 Normal: clavicle bone visible, not prominent
 Mild-Moderate: some protrusion of the bone
 Severe: protruding, prominent bone, fingers can slide under bone
Pectoralis Muscle
Deltoid Muscle
Examine the anterior and posterior acromion process
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•
•
•
Observe patient straight on with arms at side, sitting upright
Look for “squared” vs. “rounded” shoulders
Assess for protrusion of the acromion process
Squeeze the muscle at the shoulder to assess for tone and
musculature
•
•
Well-developed deltoid  taut water balloon, bag of flour, leather belt
Wasted muscle  flaccid water balloon
 Normal: rounded curves at the junction of shoulder and neck
 Mild-Moderate: some protrusion of acromion process
 Severe: prominent acromion process, “squared” appearance
Deltoid Muscle
Latissimus Dorsi and Trapezius
Examine the scapula (shoulder blade)
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•
•
•
Assess the patient from the back
Ask patient to extend hands out and push against solid object
Look for “squared off” appearance or protrusion of bone
Assess the musculature around the shoulder blade
 Normal: bone is not prominent, well rounded back
 Mild-Moderate: mild depression, bone may show slightly
 Severe: Prominent, visible bones, depression between ribs and
scapula
Latissimus Dorsi and Trapezius
Interosseous Muscle
Examine the muscle between the thumb and forefinger
• Have patient press thumb and forefinger to make the “OK” sign
• Observe the pads of the thumb side of the hand
• Palpate to assess the pads of the thumb
 Normal: muscle bulge
 Mild-Moderate: slightly depressed or flat
 Severe: flat or depressed area between thumb and forefinger
Interosseous Muscle
Quadriceps- Anterior Thigh
Examine the four muscles that make the larger
quadriceps
• Ask patient to sit and prop leg up on low furniture
• Look for rounded musculature and rounded shape going
into knee joint
• Grasp and palpate quads to differentiate muscle tissue
from fat tissue
 Normal: well rounded, no depressions between four
muscles
 Mild-Moderate: mild depression on inner thigh
 Severe: concave depression on thigh, IT band may be
visible
Quadriceps- Patellar Region
Examine the knee
• Ask patient to sit and prop leg up on low furniture
• Look for prominence of joint and squared appearance
 Normal: muscles protrude, rounded appearance of muscle, no
prominence of knee
 Mild-Moderate: knee cap more prominent, little muscle is seen
entering the joint
 Severe: knee cap is prominent, squared off appearance, no sign
of muscle around knee
Quadriceps
Gastrocnemius Muscle
Examine the calf muscle
• Assess the bulk of the muscle
• Look for symmetry of both legs
• Grasp the calf muscle to determine
amount of tissue
 Normal: well-developed, firm muscle
 Mild-Moderate: not well developed,
some shape and firmness
 Severe: thin, minimal to no muscle
definition
Gastrocnemius Muscle
Fluid Accumulation
Assessing Edema
Types of edema:
• Pitting, non-pitting
• Pulmonary, pleural
• Peripheral, pedal
• Ascites, anasarca
Additional Considerations:
• Anuric and oliguric patients are most at risk for fluid retention
• Fluid status must be taken into consideration when assessing
weight history and conducting NFPE
• Excess fluid accumulation can mask muscle and fat loss
Assessing Edema
• Take thumb and press on top of ankle, foot and/or shin for 5
seconds
Assessing Edema
Pitting Edema
Non-Pitting Edema
When pressure is applied
to small area of skin, the
indentation persists after
release of pressure
When pressure is applied
to small area of skin, the
indentation does not
persist
Assessing Edema
Distended Neck Veins
Pulmonary / Pleural
Edema
Assessing Edema
Peripheral Edema
Pedal Edema
Assessing Edema
Ascites
Anasarca
Malnutrition Case
Study
NFPE Case Study
K.Z. a 45 year old female as admitted through the Emergency Room
with a chief complaint of altered mental status, abdominal pain, and
diarrhea.
• Nutrition triggers on admit included
• Weight Loss
• Decreased appetite > 5 days
RD assessed K.Z. on day #2 of admission
Nutrition Assessment
Findings
Past Medical History
Crohn’s disease of the small intestine- diagnosed 9 months PTA
Imaging Studies
CT of head – no acute findings
CT of abdomen / pelvis – chronic inflammation of small bowel
Anthropometric Data
Admit weight: 125#
Admit Ht: 5’10”
BMI: 17.9
Usual body weight: 150#
16% unintentional weight loss in 9 months
Laboratory
Albumin 2.0 g/dL
Nutrition History
Husband reports patient with no appetite and only 25% of intake
for the past few months
NFPE Case Study
Subcutaneous Fat Loss
Areas of Subcutaneous Fat Loss
NFPE Findings
Orbital Fat Pads
Dark circles
Hollow appearance
Loose skin
Triceps
Fingers are touching when
pinching the skin
Ribs, Midaxillary Line, Lower Back Skin is stretched
Well-defined ribs
What degree of subcutaneous fat loss does K.Z. present with?
NFPE Case Study
Subcutaneous Fat Loss
Areas of Subcutaneous Fat Loss
NFPE Findings
Orbital Fat Pads
Dark circles
Hollow appearance
Loose skin
Triceps
Fingers are touching when
pinching the skin
Ribs, Midaxillary Line, Lower Back Skin is stretched
Well-defined ribs
What degree of subcutaneous fat loss does K.Z. present with?
SEVERE FAT LOSS
NFPE Case Study
Muscle Atrophy – Upper Body
Areas of Muscle Atrophy
NFPE Findings
Temporalis
Hollow depression
Pectoralis
Prominent, protruding clavicle bone
Deltoid
Prominent acromion process
Squaring of shoulder
Latissimus Dorsi and Trapezius
Protruding scapula
Muscle depression
Interosseous
Muscle wasting between finger bones
Depression between thumb and forefinger
What degree of upper body muscle atrophy does K.Z. present with?
NFPE Case Study
Muscle Atrophy – Upper Body
Areas of Muscle Atrophy
NFPE Findings
Temporalis
Hollow depression
Pectoralis
Prominent, protruding clavicle bone
Deltoid
Prominent acromion process
Squaring of shoulder
Latissimus Dorsi and Trapezius
Protruding scapula
Muscle depression
Interosseous
Muscle wasting between finger bones
Depression between thumb and forefinger
What degree of upper body muscle atrophy does K.Z. present with?
SEVERE MUSCLE LOSS
NFPE Case Study
Muscle Atrophy – Lower Body
Areas of Muscle Atrophy
NFPE Findings
Quadriceps
Prominent knee cap
“Squared-off” appearance
Little muscle surrounding knee cap
Concave muscles
Gastrocnemius
Thin
No muscle definition
What degree of lower body muscle atrophy does K.Z. present with?
NFPE Case Study
Muscle Atrophy – Lower Body
Areas of Muscle Atrophy
NFPE Findings
Quadriceps
Prominent knee cap
“Squared-off” appearance
Little muscle surrounding knee cap
Concave muscles
Gastrocnemius
Thin
No muscle definition
What degree of lower body muscle atrophy does K.Z. present with?
SEVERE MUSCLE LOSS
NFPE Case Study
Fluid Accumulation
Area of Edema
NFPE Findings
Ankles
3 – 4+ pitting edema
Feet
N/A
Hands
N/A
What degree of fluid accumulation does K.Z. have?
NFPE Case Study
Fluid Accumulation
Area of Edema
NFPE Findings
Ankles
3 – 4+ pitting edema
Feet
N/A
Hands
N/A
What degree of fluid accumulation does K.Z. have?
MODERATE TO SEVERE FLUID
ACCUMULATION
NFPE Case Study
Is K.Z. malnourished?
Yes
No
If yes, what is the etiology of malnutrition?
Acute
Chronic
Social/Environmental
What is the severity of malnutrition?
Moderate (Non-Severe)
Severe
NFPE Case Study
Is K.Z. malnourished?
Yes
No
If yes, what is the etiology of malnutrition?
Acute
Chronic
Social/Environmental
What is the severity of malnutrition?
Moderate (Non-Severe)
Severe
NFPE Case Study
Nutrition Care Process – PES Statement
Severe malnutrition of chronic illness related to
inadequate intake as evidenced by 16% weight loss in
the past nine months, consuming less than 25% of
energy needs for greater than one month, severe
bilateral muscle atrophy of upper and lower body,
and severe loss of subcutaneous fat to orbital fat
pads, triceps and ribs.
Call to Action!
Ingalls Hospital Experience
• Clinical dietitians formed a Malnutrition Task Force
• Clinical dietitians developed a resource booklet to assist
dietitians and dietetic interns in performing NFPE
• Abbott Nutrition representative presented malnutrition
education programs to dietitians and information
documentation specialists
• Dietitians collaborated with information documentation
specialists on NFPE findings for individual patients to assist in
proper coding of malnutrition
How to put NFPE into practice
Start with a small sample population
• Perform NFPE on designated unit or disease state
Document
• Develop a checklist or measurement tool
• Document findings in the electronic medical record
Utilize a check and balance system
• Compare NFPE findings with peers
Collaborate with interdisciplinary team
• Physicians, nurses
• Information documentation specialists
NFPE Resources
Abbott Nutrition Health Institute
• “Patient Simulation” course
• ANHI Certificate of Training in Adult Malnutrition
Dietitians in Nutrition Support Symposium
• Annually in June
American Society of Parenteral and Enteral Nutrition (ASPEN)
• Malnutrition Webinars
• Nutrition Focused Physical Exam – an illustrated handbook
Academy Medical Systems
• NFPE Assessment Webinar
Academy of Nutrition and Dietetics
• Nutrition Focused Physical Exam Pocket Guide
• Nutrition Focused Physical Exam Hands-on Training Workshop
Food and Nutrition Conference and Expo (FNCE)
• October 2017
Thank you!
Question?
Trudi Coleman, MS RD LDN
[email protected]
Annelise Chmelik, RD LDN
[email protected]
References
• Barker LA, Gout BS, Crow TC. Hospital malnutrition: prevalence, identification and impact on
patients and the healthcare system. Int J Environ Res Public Health. 2011;8(2):514-527.
• Jensen GL. Inflammation as the key interface of the medical and nutrition universes: a provocative
examination of the future of clinical nutrition and medicine. JPEN J Parenter Enteral Nutr.
2006:30(5)453-463
• Jensen GL, Bistrian B, Roubenoff R, Heimburger DC. Malnutrition syndromes: a conundrum vs
continuum. JPEN J Parenter Enteral Nutr. 2009;33(6):710-716
• Jensen GL, Mirtallo J, Compher C, Dhaliwal R, Forbes A, Grijalba RF, Hardy G, Kondrupo K,
Labadarios D, Nyulasi I, Castillo Pineda JC, Waitzberg D. Adult starvation and disease-related
malnutrition: a proposal for the etiology-based diagnosis in the clinical practice setting from the
International Consensus Guideline Committee. JPEN J Parenter Enteral Nutr. 2010; 34(2):156-159
• Jensen GL, Hsiao PY, Wheeler D. Adult nutrition assessment tutorial. JPEN J Parenter Enteral Nutr.
2012;36(6):267-274.
• Jensen GL, Wheeler D. A new approach to defining and diagnosing malnutrition in critical illness.
Curr Opin Crit Care. 2012;18(2):206-211.
• Jensen GL, Hsiao PY, Wheeler D. “Nutrition screening and assessment.” In the ASPEN Adult
Nutrition Support Core Curriculum: 3rd edition. Mueller C, ed. American Society for Parenteral and
Enteral Nutrition. 2012; 155-169.
References
• Nutrition Screening Adults / Nutrition Screening (NSCR) Systematic Review. NSCR: Serum Proteins:
Albumin and Prealbumin (2009). Academy of Nutrition and Dietetics Evidence Analysis Library.
Accessed May 23, 2017.
• Snider JT, Linthicum MT, Wu Y, LaVelle C, Lakdawalla DN, Hegazi R, Matarese L. Economic burden
of community-based disease-associated malnutrition in the United States. JPEN J Parenter Enteral
Nutr. 2014;38(S2):77S-85S.
• Tappenden KA, Quatrara B, Parkhurst ML, Malone AM, Fanjiang G, Ziegler TR. Critical role of
nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital
malnutrition. JPEN J Parenter Enteral Nutr. 2013;37:482-497.
• White JV, Guenter P, Jensen G. Consensus statement of the Academy of Nutrition and
Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for
the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet.
2012;112:730-738.