9/14/2011
The Skeleton’s Out:
A Standardized Approach to
the Recognition and
Documentation of
Malnutrition
Jane White, PhD, RD, FADA
Annalynn Skipper, PhD, RD, FADA
September 25, 2011
Objectives
• Review the development of evidence-based/consensus
ADA / A.SP.E.N. Committees
• ADA Malnutrition Workgroup • ASPEN Malnutrition Task
determined characteristics of malnutrition
• Promote the characteristics standardized use
• Encourage data collection to validate this approach to
malnutrition diagnosis and characterization
Force
–
Maree Ferguson MBA, PhD, RD
–
Annalynn Skipper, MS, PhD, RD, FADA
–
Louise Merriman, MS, RD, CDN
–
Terese Scollard MBA, RD, LD
–
Sherri Jones MS, MBA, RD, LDN
–
Ainsley Malone, MS, RD, LD, CNSD
– Nilesh Mehta, MD, DCH
–
Jane White PhD, RD. FADA, LDN, Chair
– Steve Plogsted, PharmD, RPh, BCNSP
–
Staff: Pam Michael, MBA, RD,
– Annalynn Skipper, PhD, RD, FADA
–
Staff: Marsha Schofield, PhD, RD
– Jennifer Wooley, MS, RD, CNSD
– Gordon L. Jensen, MD, PhD, Co-Chair
– Ainsley Malone, MS, RD, CNSC, Co-Chair
– Rose Ann Dimaria, PhD, RN, CNSN
– Christine M. Framson, RD, PHD, CSND
– Jay Mirtallo, RPh, BCNSP Board Liasion
– Staff: Peggi Guenter, PhD, CNSN
In-Patient Prospective Payment System – MS-DRGs
• 1983 –Diagnosis Related Groups (DRGs)
– Malnutrition recognized as a secondary diagnosis or “cc” (complication
/ co-morbid condition)
– DRG relative weights on estimated hospital costs, rather than
charges. (Medicare & Medicaid)
• 2007 – Medical Severity DRG (MS DRGs)
– Recognize malnutrition as impacting acuity and severity of patients,
so reimbursement may be increased due to increased cost of care
Rationale for Developing ADA/A.S.P.E.N Characteristics
to Identify Malnutrition:
•
No standardization
• Multiple Definitions
• Multiple Diagnostic (ICD-9)Codes
• Multiple characteristics used to Diagnosis
• Limited evidence base
• Emerging role of inflammation
• Influence on Assessment Parameters
• Influence on Response to Nutrition Intervention
• Anti-inflammatory Interventions / Nutrition interventions outcomes
divergence
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9/14/2011
A Vision for the Identification of Malnutrition
in all Settings
Wouldn’t it be amazing to have standardized
definitions/characteristics and to know the prevalence of
Adult Malnutrition in…
Our Country
Our Health System
Our
Our
World
World
Rationale for Developing Characteristics to
Identify Malnutrition
Hospital chain, under scrutiny,
reports rare illness
• February 20, 2011
• By LANCE WILLIAMS, CHRISTINA JEWETT and
STEPHEN K. DOIG
California Watch
• Redding, near Mount Shasta, and Victorville, in the Mojave
Desert, have little in common but an unusual statistic: In each
city, a hospital has reported alarming rates of a Third World
nutritional disorder among its Medicare patients.
• Kwashiorkor -- a Ghanaian word for "weaning sickness" --
almost exclusively afflicts impoverished children in developing
countries, especially during famines, experts say.
ADA/A.S.PE.N Member Inquiries
Poll Question 1
• ADA/A.S.P.E.N have received numerous requests from
•Do you use Albumin in
RDs, physicians, nurses and other professionals:
• How to diagnose malnutrition
• How to document malnutrition
diagnosing/documenting malnutrition?
Yes
No
• Correlation of current IDNT definitions with existing diagnostic
coding terminology
• Which characteristics to use
Why not serum proteins (albumin / prealbumin, etc.)???
Poll Question 2
•Do you use prealbumin in
documenting/diagnosing malnutrition?
Yes
No
Why not serum albumin/visceral proteins?
Gordon Jensen, MD, PhD
• Acute Phase Response
– Inflammatory disease, illness, injury elicit cytokinemediated response
– Interleukin-1(IL-1), interleukin-6 (IL-6), tumor necrosis
factor (TNF)
– Alter hormone secretion and target organ function
– Favor a catabolic state
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9/14/2011
Why not serum albumin/visceral proteins?
Gordon Jensen, MD, PhD
•Acute Phase Metabolic Response
– Elevation of resting energy expenditure
Poll Question 3
•Do you use C Reactive Protein to interpret
albumin or prealbumin?
– Export of amino acids from muscle to liver
Yes
– Increase in gluconeogenesis
No
– Expansion of extracellular fluid
– Shift toward production of positive acute phase
reactants, i.e. CRP
Why not serum albumin/visceral proteins?
Why not serum albumin/visceral proteins?
Gordon Jensen, MD, PhD
Body down regulates albumin synthesis so that
urgently needed proteins for immune, clotting,
and wound healing functions can be made.
• Positive - antibodies, complement, C-reactive protein, and
fibrinogen
• Negative - albumin, transferrin, prealbumin, retinol binding
protein
– Over the short run the acute phase metabolic response with
resulting catabolism is likely an appropriate adaptive response.
– If the underlying stressor is severe, protracted or repeated, then
adverse outcomes will result.
Roles of cytokines in muscle regulation in
inflammation
Gordon Jensen, MD, PhD
Gordon Jensen, MD, PhD
• Malnourished individuals
(pure semi-starvation) may exhibit
normal visceral proteins (anorexia nervosa).
• Obese persons in diet programs with low protein and energy
intakes and resulting weight loss may exhibit normal proteins.
– Changes in body cell mass correlate poorly with visceral proteins.
– Changes in dietary intake correlate poorly with visceral proteins.
– Sick people eat less.
• Other disease states impact visceral protein synthesis or losses.
– Volume status can limit interpretation.
– Protracted half-life of albumin renders it insensitive to measure changes
in status.
– Prealbumin suffers most of the same limitations but has a shorter half-life.
Inflammation promotes--Gordon Jensen, MD, PhD
– Metabolic dysregulation
• Promote muscle catabolism
• Inhibition of protein synthesis and muscle repair
• Trigger apoptosis – programmed cell death
• Influence contractility and function
– Hyperglycemia
– Decreased visceral proteins
– Muscle catabolism
– Edema
– Anorexia
– Malaise / deconditioning
• Nutrition alone is ineffective in preventing muscle
protein loss in inflammation
Inflammation can blunt favorable responses to
nutrition intervention
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9/14/2011
“Practical” Indicators of Inflammation?
Gordon Jensen, MD, PhD
• Lab
ADA Evidence Analysis: Albumin/Prealbumin
• ADA Evidence Analysis Library Resources on Albumin and
– Albumin, prealbumin
Prealbumin:
– C-reactive protein (CRP)
http://www.adaevidencelibrary.com/conclusion.cfm?conclusi
on_statement_id=251
263&highlight=albumin&home=1
– Cytokines - IL-6
– Procalcitonin
• Clinical signs
– Fever, leukocytosis, hyperglycemia
http://www.adaevidencelibrary.com/conclusion.cfm?conclusi
on_statement_id=251
313&highlight=prealbumin&home=1
Clinical Diagnostic Expertise Needed
ADA Evidence Analysis: Albumin/Prealbumin
• Does serum albumin correlate with weight loss in four
models of prolonged protein-energy restriction: anorexia
nervosa, non-malabsorptive gastric partitioning bariatric
surgery, calorie-restricted diets or starvation?
– In the four models of prolonged protein-energy restriction, there was no
correlation between serum albumin and weight loss.
– Grade II
• Does serum prealbumin correlate with weight loss in four
models of prolonged protein-energy restriction: Anorexia
nervosa, non-malabsorptive gastric partitioning bariatric
surgery, calorie-restricted diets or starvation?
Proposal by ADA/A.S.P.E.N. to NCHS
JPEN 2009; 33:710-716; JPEN 2010: 34:156-9
• Define the characteristics of adult malnutrition syndromes in
developed countries using an etiology-based approach that
incorporates an appreciation of the continuum of inflammatory
response.
• Recognize the contributors to the development of malnutrition:
– Semi starvation
– Inability to assimilate nutrients consumed
– Systemic inflammatory response
– In the four models of prolonged protein-energy restriction, there was no
correlation between serum prealbumin and weight loss.
– Grade III
ADA/A.S.P.E.N. Joint Recommendation to
NCHS - Results-to-Date
•The National Center for Health Statistics (NCHS) has received multiple
Etiology Based Malnutrition Definitions
requests to clarify the malnutrition diagnosis codes and use of the codes
Nutritional Risk Identified
• ADA and A.S.P.E.N. submitted recommendations (September 2010 and
Compromised intake or
loss of body mass.
March 2011public hearings)
• Current decision regarding the proposed revisions to the existing malnutrition
code definition(s).
Jensen GL. JPEN 2009;33:710
Inflammation present? No / Yes
– No change at this time to 262 (severe Malnutrition) and 263 (Other and
unspecified protein-calorie malnutrition)
• ICD-9/ICD-10 transition in 2014 – new codes possible at this time
• Continue to try to identify language that allows development of pre-coordinated
codes
– Language to qualify the use of kwashiorkor and marasmus
• Pediatric populations
• Poorly resourced countries, typically
Yes
No
Starvation Related
Malnutrition
(pure chronic starvation,
anorexia nervosa)
Mild to Moderate
Degree
Chronic Disease – Related
Malnutrition
(organ failure, pancreatic
cancer, rheumatoid arthritis,
sarcopenic obesity)
Yes
Marked
Inflammatory
Response
Acute Disease or InjuryRelated Malnutrition
(major infection, burns,
trauma, closed head injury)
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9/14/2011
Consensus Regarding Malnutrition Definition
Characteristics to Identify Malnutrition
• Constraints:
• ADA Workgroup agrees with the A.S.P.E.N./International
Work Group’s etiologically–based system of malnutrition
classification that recognizes the influence of inflammation
on nutritional status
• A.S.P.E.N.’s Malnutrition Workgroup has accepted the ADA
Workgroup’s proposed characteristics.
• Basic parameters (hallmarks, few in total #)
• Support diagnosis of malnutrition
• Characterize severity
•  as nutritional status changes
• Evidence-based (when possible) / expert opinion
• Will change over time as evidence of validity accrues
• Any 2 or more characteristics may be used to
identify Malnutrition
Characteristics to Identify Severe Malnutrition
Characteristics to Identify Non-Severe
(moderate) Malnutrition
• Evidence of Reduced Intake
• Evidence of reduced Intake
– Compromised intake of varying degree and duration
• > 5 days with intake of < 50% of total estimated energy requirement (acute
illness/injury category)
• > 1 month with intake of <75% total estimated energy intake (chronic disease
category)
– Compromised intake of varying degree and duration
– Evidence of suboptimal intake
• > 7 days with a nutrient intake of <75% of total estimated energy requirements
(acute injury/illness category)
• > 1month days with a nutrient intake of <75% of total estimated energy
requirements (chronic illness/condition category)
• > 1 month with intake of < 50% total estimated energy intake
(environmental/social circumstances category)
• > 3 months with a nutrient intake of < 75% of total estimated energy requirements
(environmental/social circumstances categories)
• avoid contributing to iatrogenic malnutrition in these patients*
• avoid contributing to iatrogenic malnutrition in these patients
* A number of people with acute or chronic illness/trauma may present as
“apparently healthy” without prior history of malnutrition or chronic disease. As
such, unintended weight change and inability to eat may be the main parameters
of significance, although the presence of low or excessive BMI, when present,
could signify increased risk.
People with illness/trauma may present as “apparently healthy” without prior
history of malnutrition or chronic disease. As such, inability to eat and
unintended weight change may be the parameters of significance for people
in this category also, although the presence of low or excessive BMI, when
present, could signify increased risk.
Characteristics to Identify Severe Malnutrition
Characteristics to Identify Non-Severe
(moderate) Malnutrition
•Unintended Weight Loss
• Unintended Weight Loss
• Interpretation of Percent Weight Loss**
Severe (%)
Time
>2
1 week
>5
1 month
> 7.5
3 months
>10
6 months
> 20
1 year
• Interpretation of Percent Weight Loss**
Significant (%)
**Height, weight
and usual weight
need to be
obtained in order
to determine the
percentage and
interpret the
significance of
weight loss.
Time
1- 2
1 week
5
1 month
7.5
3 months
10
6 months
20
1 year
**Height, weight
and usual weight
need to be
obtained in
order to
determine the
percentage and
interpret the
significance of
weight loss
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9/14/2011
Characteristics to Identify Malnutrition
Characteristics to Identify Malnutrition
• Changes in Body Composition
– Muscle Loss
Changes in Body Composition
» Loss of lean mass at temples
(temporalis muscle); clavicles
(pectoralis & deltoids); shoulders
(deltoids); interosseous muscles;
scapula (latissimus dorsi, trapezius,
deltoids); thigh (quadriceps) and
calf (gastrocnemius
– Loss of Subcutaneous Fat
» orbital, triceps, fat overlying the ribs
» Mild in non-severe malnutrition
» Moderate to severe in severe malnutrition
» Mild in non-severe
malnutrition
» Moderate to severe in severe
malnutrition
Mild
Characteristics to Identify Malnutrition
Assessing Changes in Body Composition
Changes in Body Composition
• Assessing Edema, 2 methods:
– 1+ Mild pitting, slight indentation, no perceptible swelling (2mm)
• Fluid accumulation##
– 2+ Moderate pitting, indentation subsides rapidly (4mm)
– Localized (extremities or scrotal edema)
– 3+ Deep pitting, indentation remains a short time,
extremity looks swollen (6mm)
– Generalized fluid accumulation - clinically evident edema on
examination
»Mild in non-severe malnutrition
Severe
– 4+ Very deep pitting, indentation lasts a long time,
extremity is very swollen (8mm)
• Or
»Moderate to severe in severe malnutrition
– 1+ if the pitting lasts 0 to 15 sec
– 2+ if the pitting lasts 16 to 30sec
## May mask
– 3+ if the pitting lasts 31 to 60sec
weight loss, might be reflected as weight gain
– 4+ if the pitting lasts >60sec
Assessing Changes in Body Composition
Characteristics to Identify Malnutrition
• Assessing/Documenting Changes in Body Composition:
• Measures of Physical Function/Performance
– (for each trait specify: 0 = normal, 1+ = mild, 2+ = moderate, 3+ = severe)
•#
•#
•#
•#
•#
__________loss of subcutaneous fat (triceps, ribs, orbital)
__________muscle wasting (quadriceps, deltoids, etc.)
__________extremity edema (hand/arm, ankle/leg)
__________vulvar/scrotal edema
__________generalized edema
•
•
•
•
•
•
(proxy for lean mass?)
Hand Grip Strength *
•
•
•
•
Dynamometer
Standards (excellent, good, average, fair, poor) for dominant hand by gender and age
Maximum reading (kg) from 3 attempts, allow 1 minute rest between attempts
Measurably reduced
4-meter/other walk tests ^
Stair climbing/chair rising/balance ^
Peak Expiratory Flow/Lung Function Parameters being explored
Fair results - Moderate Malnutrition
Poor results – Severe malnutrition
*Strongest correlation to date with muscle mass and nutritional status
^ Elderly populations
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9/14/2011
ADA/ A.S.P.E.N. Caveats
Questions
• Characteristics to Identify Malnutrition
• Work in progress
• Parameters may change over time
• Evidence to support their appropriateness
• collected and evaluated on a broad scale – start data collection now
• Impact of inflammation on
• nutrient requirements/utilization
• response to nutrition intervention
• clinical markers of inflammation most relevant in malnutrition
• All are yet to be determined
ADA/A.S.P.E.N. Malnutrition Workgroup c/o
Jane V. White, PhD, RD, Chair ADA MN-WG at: jwhite13@uthsc.edu
Marsha Schofield, MS, RD, ADA staff liaison at: mschofield@eatright.org
Ainsley Malone, MS, RD, CNSC, Co-Chair A.S.P.E.N. Malnutrition Task
Force at: ainsleym@earthlink.net
Bibliography
1.
Jensen GL, Bistrian B, Roubenoff R, Heimburger DC.
Malnutrition syndromes: a conundrum vs continuum.
JPEN Nov-Dec 2009;33:710-716.
2.
Jensen GL, Mirtallo J, Compher C, et al. Adult starvation
and disease-related malnutrition: a proposal for etiologybased diagnosis in the clinical practice setting from the
International Consensus Guideline Committee. JPEN
Mar-Apr;34:156-159.
3.
Norman K, Stobaus N, Gonzalez MC, Schulzke J-D,
Pirlich M. Hand grip strength : Outcome predictor and
marker of nutritional status. Clinical Nutrition.
2011;30:135-142.
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