Copyright 2013 Abbott Nutrition - Part 1
Disclosures
Faculty
Consultant
Speaker’s Bureau
Grants
Alison Steiber
Abbott Nutrition
Pentech Health
Abbott Nutrition
Pentech Health
Genzyme
BioGaia
Abbott Nutrition
Kelly Tappenden
Abbott Nutrition
NPS Pharmaceuticals
Nutricia
Nestlé
Abbott Nutrition
This session is supported by Abbott Nutrition Health Institute.
Honoraria and travel expenses were provided to the faculty
participants.
Session Objectives
The Time is NOW!
Elevating the Role of Nutrition
for Better Patient Outcomes
Speakers:
Alison Steiber, PhD, RD
Terese Scollard, MBA, RD, LD
Moderator:
Kelly Tappenden, PhD, RD, FASPEN
1. Describe the physiology of malnutrition and
approaches to assess the malnourished patient
2. Identify the need to use the recommended
malnutrition-related diagnostic characteristics
to assess and document nutrition status in adults
3. Demonstrate how consistent documentation
enables clinicians to better establish
prevalence and in turn, initiate effective
nutritional interventions
Question: In current clinical practice, malnutrition
is best described by which of the following
Question: In current clinical practice, malnutrition
is best described by which of the following
1. marasmus
2. kwashiorkor
3. disease-related
malnutrition
4. nutrient specific
deficiency
1. marasmus
2. kwashiorkor
3. disease-related
malnutrition
4. nutrient specific
deficiency
48%
37%
11%
5%
1
2
3
4
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Copyright 2013 Abbott Nutrition - Part 1
Inflammation is a central component of
health and disease
Key characteristics of undernutrition syndromes
Undernutrition
syndrome
Characteristics
Wasting
Loss of body cell mass without underlying inflammatory condition.
Visceral proteins preserved.
Extracellular fluid not increased.
Sarcopenia
Aging-related muscle loss without other precipitating causes.
Cachexia
Loss of body cell mass with underlying inflammatory condition.
Decline in visceral proteins.
Increased extracellular fluid.
Protein-energy
undernutrition
Clinical and laboratory evidence for reduced dietary intake of
protein and energy.
Reduced visceral proteins.
Failure-to-thrive
Weight loss and decline in physical and/or cognitive functioning with
signs of hopelessness and helplessness.
Etiology-Based Definition of Malnutrition
there is chronic starvation without
Starvation-related • When
inflammation
malnutrition
• Pure chronic starvation, anorexia nervosa
Chronic diseaserelated
malnutrition
• When inflammation is chronic and of mild
to moderate degree
• Organ failure, pancreatic cancer,
rheumatoid arthritis, or sarcopenic obesity
Acute diseaseor injury-related
malnutrition
• When inflammation is acute and of severe
degree
• Major infection, burns, trauma or closed
head injury
Jensen et al., JPEN 2010;34:156-159
Jensen. JPEN 2006;30:453-463.
Relationship between malnutrition and the
inflammatory condition
Jensen et al., JPEN
2010;34:156-159
Question: What is the estimated prevalence of
malnutrition among hospitalized patients
1.
2.
3.
4.
20%
35%
50%
65%
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Copyright 2013 Abbott Nutrition - Part 1
Question: What is the estimated prevalence of
malnutrition among hospitalized patients
1.
2.
3.
4.
20%
35%
50%
65%
Prevalence of Malnutrition in Hospitals
• 30-50% of patients are
malnourished upon admission1
45%
Up to
• A 2011 Johns Hopkins study
showed that 53% of patients are
malnourished2
31%
23%
• 38% of patients with normal
nutrition status experience decline
during hospitalization3
1%
1Correia
1
2
3
4
A Changing Healthcare Landscape
and Campos. Nutrition 2003;19:823-825.
JPEN 2011;35:209-216.
et al. JADA 2000;100:136-1322.
2Somanchi.
3Braunschweig
Question: Which of the following indicators is least
useful in diagnosing malnutrition?
1. insufficient energy
intake
2. weight loss
3. serum albumin
4. fluid accumulation
12010
HIDA Acute Care Market Report, Alexandria Va. www.HIDA.org
Question: Which of the following indicators is least
useful in diagnosing malnutrition?
1. insufficient energy
intake
2. weight loss
3. serum albumin
4. fluid accumulation
Academy and ASPEN Consensus: Characteristics Recommended for
the Identification and Documentation of Adult Malnutrition
Insufficient
energy intake

functional
status
51%
Weight
loss
Adult
Malnutrition
24%
14%
(if ≥2 present)
 muscle
mass
Fluid
accum
11%
 Subcut
fat
1
2
3
4
White et al., JAND 2012;112:730-738.
White et al., JPEN 2012;36:275-283.
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Copyright 2013 Abbott Nutrition - Part 1
Claiming CPEU Credit
Please use the certificate provided to you
as you leave the session today.
Be sure to log this session into your PDP
plan and submit for your state licensure.
This program is CPE level 2.
Objectives
• Describe the physiology of malnutrition and approaches
to assess the malnourished patient
• Recognize the need to use the recommended
malnutrition-related diagnostic characteristics to assess
and document nutrition status in adults
Malnutrition Characteristics
•
•
•
•
•
•
Energy Intake
Weight Loss
Body Fat
Muscle Loss
Fluid accumulation
Reduced Grip Strength
Definition = a minimum of 2
characteristics present
IDNT Manuals
Commitment to Quality
Nutrition Care:
• Standardized language
is a basic requirement.
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Copyright 2013 Abbott Nutrition - Part 1
Malnutrition in IDNT (IDNT Book, 4th ed.)
Evidence
Based
Practice
Guidelines
Other Research
• Malnutrition (NI-5.2)
– Inadequate intake of protein and/or energy over prolonged periods of
time resulting in loss of fat and/or muscle stores including starvationrelated malnutrition, chronic disease or condition-related malnutrition
and acute disease or injury-related malnutrition
ClinicalPractice
• Signs and Symptoms include:
Assessment
Outcomes
Research
IDNT
Diagnosis
Intervention
Monitoring & Evaluation
IDNT malnutrition (s/s cont.)
IDNT malnutrition (s/s cont.)
IDNT, e4, 2013
IDNT book, 4th
ed., 2013
White et al, JAND, 2012
White et al, Journal of the Academy of Nutrition and Dietetics, 2012
Mr. Richard
Clinical Information
•
•
•
Patient Medical History
84 years old, male
Admitted for Chemo
Height = 5’7” (170 cm)
– Current Weight = 62 kg
– Usual Body Weight (UBW) = 82 kg;
Ideal Body Weight (IBW) = 67 kg
– % UBW = 76%
– Weight loss = 20.5kg (25%) in 2 ½ months
• Previous Dx of nodular melanoma & subsequently with
cervical lymphadenopathy, has Type 2 Diabetes Mellitus
• Reason for admission:
– After 2nd cycle of chemo pt. had colonic perforation and diffuse
peritonitis
– Mouth sore
– Surgery for total colectomy/ileostomy and jejunostomy feeding
tube was placed
– Transient fevers
– On TPN/TF for 5 days, transitioned to nocturnal TF and oral diet
• Reports decreased appetite, intake
and swallowing problems that impair
ability to eat adequately
 Pt transferred to a skilled nursing facility (SNF)
 AT SNF the tube began leaking, was replaced, but not being used.
 Eating small meals and regular texture foods
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Copyright 2013 Abbott Nutrition - Part 1
Physical Assessments:
Clinical Findings: Nutrition Focused Physical
Exam: Example = Mouth
• Subjective Global Assessment
• Nutrition focused physical exam
Angular Stomatitis
Glossitis
Magenta Tongue
Thrush
Clinical Findings: SGA & Nutrition Focused
Physical Exam
Hypertrophied Papillae
Geographic Tongue
Subjective Global Assessment in Second Life
• Subjective Global
Assessment
– Score 4 = moderate nutrition
loss
• Muscle wasting:
– Temples, interosseous,
shoulder
• Fat store wasting
– Fat pads under the eye
Question 1. What would you identify as the major
nutrition problems?
Question 1. What would you identify as the major
nutrition problems?
1.
2.
3.
4.
1.
2.
3.
4.
Inadequate Protein-Energy Intake
Malnutrition
Underweight
Others??
Inadequate Protein-Energy Intake
43%
Malnutrition
Underweight
Others??
42%
6%
1
2
3
9%
4
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Copyright 2013 Abbott Nutrition - Part 1
Nutrition problems/Diagnoses (adult) per IDNT
Problem
BCH data
Anthro
NFPE
Food/diet
Client hx
Inadequate P‐ Normal
alb
E Intake (NI‐
5.3)
Wt loss of 7% in 3mo; >5% in 1 mo; 1‐2% in 1 wk
Slow wound healing
Est intake is < RMR; restriction
of food groups, et al
Nutr mal‐
absorption; conditions assoc. w/PEM
Malnutrition [can occur at any BMI] (NI‐
5.2)
Loss of BMI<22 (>65y/o), FTT, Wt loss (malnut subcutaneous fat;
Fluid retention
characteristics*)
Underwt. with fat & muscle loss
Est intake is < RMR;
Change in functional
indicators
Major infections
Unintended Wt Loss (NC‐
3.2)
Wt loss of > 5% within 30 d; 7.5% in 90d; 10% in 180d
nl or usual est. intake in face of illness; poor intake, meds associated with wt loss
Conditions associated with dx or txt, cancer chemotherapy
Fever, ↓ senses, ↑ heart rate, ↑ resp.
rate, loss of subcutaneous fat & muscle
Impact of Malnutrition in the Elderly:
Fitting the pieces together
Mal‐
nutrition
Sarcopenia
Frailty
Per IDNT terminology, 4rd ed, 2013
BCH = biochemical data, NFPE = nutrition focused physical exam
Frailty in elderly
What is sarcopenia?
• Definition of frailty
• An age-related loss of skeletal muscle mass and strength
(Fried et al, J Gerontol A Biol Sci Med Sci. 2001,)
– From Greek origin, sarx “flesh” and penia “loss”
– Meet 3 of the following criteria:
– Accompanied with increase in fat mass, connective tissue
 unintentional weight loss,
 exhaustion,
• Associated with impaired function, disabilities, and loss of
independence
 weakness,
 slow walking speed,
 low physical activity
↑Age
↓ Muscle Mass
↑ Fat Mass
• Frailty is associated with increased risk of falls,
↓ Func on,
↑ Disease risk
hospitalization, disability, and death
Dreyer et al, 2005; Evans et al, 2004; Kameler al, 2003; Iannuzzi‐Sucich et al, 2002; Paddon‐Jones et al, 2008
Sarcopenia
Prevalence:
• 13-24% of those ≥ 65 years old
(Bouchard et al, 2009)
– Varies when adjusted for age and sex
• > 50% after 80 years of age
– Associated with 3 to 4-fold increase in the likelihood of a
functional disability (Kamel et al, 2003, Paddon-Jones et al, 2008)
• Number of Americans > 65 years old is rising
Young, active
Old, sedentary
– Increasingly important public health concern
 May increase need for assistance of activities of daily living (ADLs)
Roubenoff, 2003
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Copyright 2013 Abbott Nutrition - Part 1
Nutrition and sarcopenia
Nutrition Status Etiology: Inflammation??
• Insufficient caloric intake among elderly
• Assess Potential for Inflammation
Step 1 • [Ex. Access Site, Temperature, GI Symptoms, Co‐morbidities, Dental]
– Malnutrition
– Due to a combination of factors
• Identify Sources of Inflammation
 Sensory losses, social isolation, fears, disease, etc.
Step 2 • [Skin Break Down, Wounds, Redness or Irritation, Inflamed Gums, UTI, Fever]
– Prefer carbohydrates and fat over protein
• Reduce or Eliminate sources of Inflammation
Step 3 • [Refer to dentist, consult for wound or access care, low dose antibiotics, omega 3 FA]
Mr. Richard Volpi et al, 2004, Kamel et al, 2003, Evans et al, 2004, Gaffney‐Stomberg et al, 2009, Question 2. Did Mr. Richard have malnutrition or
inflammation or both?
Step 2: Clinical Events Associated
with Inflammation
1. Pure Malnutrition
2. Pure Inflammation
3. Both
Snaedal, et al. Mapping of Inflammatory Markers in CKD – (MIMICK). AJKD. 2009:53;1024–1033.
Question 2. Did Mr. Richard have malnutrition or
inflammation or both?
Energy & Protein Requirements
1. Pure Malnutrition
2. Pure Inflammation
3. Both
Energy
96%
• 35 kcal/kg
• Actual Wt
2%
1
Protein
• 1.3 g/kg
• Actual Wt
3%
2
3
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Copyright 2013 Abbott Nutrition - Part 1
Question 3. Do you agree with these protein &
energy requirements?
Question 3. Do you agree with these protein &
energy requirements?
1. No needs higher protein
2. No needs higher energy
3. No needs higher energy
and protein
4. Yes I agree
1. No needs higher protein
2. No needs higher energy
3. No needs higher energy
and protein
4. Yes I agree
65%
20%
8%
1
2
3
4
Question 4. What are nutrition interventions you would be
willing to try with this patient to improve his nutrition status?
Nutritional Interventions:
Inflammation Management
1. Do a nutrition education for high
kcal/protein foods in the diet.
2. Resume high kcal oral
supplement.
3. Recommend specific vitamin or
mineral supplements
4. Recommend high kcal, high
protein tube feed via j-tube
5. None of the above
• Assess Potential for Inflammation
Step 1 • [Ex. Access Site, Temperature, GI Symptoms, Co‐morbidities, Dental]
• Identify Sources of Inflammation
Step 2 • [Skin Break Down, Wounds, Redness or Irritation, Inflamed Gums, UTI, Fever]
• Reduce or Eliminate sources of Inflammation
Step 3 • [Refer to dentist, consult for wound or access care, low dose antibiotics, omega 3 FA]
Question 4. What are nutrition interventions you would be
willing to try with this patient to improve his nutrition status?
1. Do a nutrition education for high
kcal/protein foods in the diet.
2. Resume high kcal oral
supplement.
3. Recommend specific vitamin or
mineral supplements
4. Recommend high kcal, high
protein tube feed via j-tube
5. None of the above
6%
Nutritional Monitoring
• Enteral Nutrition Tolerance
56%
– GI symptoms
 Diarrhea
 Bloating
 Gas
– Other Potential Biochemistries
18%
19%
 Glucose Monitoring
5%
2%
1
2
3
4
 Refeeding indices
5
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Copyright 2013 Abbott Nutrition - Part 1
Nutrition Care Process
Nutrition Care Process
* Wt loss
* Fat/muscle loss
Assessment
Screening
* Fever/Chem. * Mouth inflammation
Monitor, Measure & Evaluation
Diagnosis: ID
Nutrition Problem
ID etiology
Intervention
Summary
Monitored wt (AD 1.1.2), body comp. (PD 1.1.1), TF tolerance Malnutrition NI – 5.2
Nocturnal high kcal/protein TF (ND 2.1)
Inflammation
+
High kcal/protein diet (ND 1.1)
Thank You!
• Malnutrition needs to be identified using a
standardized language with validated characteristics
• Inflammation is a major contributor to Protein Energy
Wasting and thus needs to be identified and
managed by the nutrition team
• Following the Nutrition Care Process may ensure
more holistic care and thus improved patient
outcomes
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