Novel Diagnostic Criteria and Intervention of Malnutrition during Hospitalization :

Beyond BMI

Poernomo Boedi Setiawan

Department of Internal Medicine

Airlangga University Faculty of Medicine – Dr Soetomo Teaching Hospital

PIN PAPDI XVII , Hotel Shangri - La Surabaya 4 – 6 Oktober 2019

Outline presentation

Malnutrition , impact on Hospitalized patients

Nutrition screening :

BMI and

Low Lean Mass

Recent criteria / recommendation

• BEYOND BMI

Outline presentation

Malnutrition , impact on Hospitalized patients

nutrition screening :

BMI and

Low Lean Mass

Recent criteria / recommendation

• BEYOND BMI

Malnutrition ESPN conceptual definition

“ A state resulting from lack of intake or uptake of nutrition that leads to altered of body composition (decrease fat free

mass) and body mass leading to diminished physical and mental function

and impaired clinical outcome from disease “

Cenderholm et al , Clin Nut 2017

Malnutrition in hospital

7

30 – 50 % were malnourished at

admission1

1/3 well-nourished patients at admission

became undernourished

during hospitalization2,3

Weight loss + loss of muscle mass

increased 26% READMISSION risk4.5

1. Sriram K, Sulo S et al, J Parenter Enteral Nutr 2017;41: 3842. Braunschweigh et al, J Am Diet Assoc 2000; 100(11): 1316-13223. Tappenden, J Acad Nutr Diet 2013; 113: 1219-12374. Gariballa S, Elessa A Clinical Nutrition 20135. Allaudeen N et al. J Hosp Med 2011; 6: 54

8

Am J Cliii Nutr 1997;66:1232-9

45 %

57 %

Malnutrition in hospital and long term care : up to 50% of patients

9

Malnutrition: negatively impacted to outcomes and cost of hospitalized patients

• Increased medical care cost

• Increased need for drugs

• Increased length of hospital stay

• Increased risk of admission to hospital

Naberhuis JK, et al. Nutrition and Dietary Supplements 2017:9 55–62

Contribute to under - nutrition

• Difficulty swallowing

• GI symptoms: constipation, thirst, nausea

• Changing nutritional requirements (protein intake)

GI problems

• Restrictive therapeutic diets

• Drugs and polypharmacy (decrease appetite)

Diseases and pain

• Food preferences (limited)

• Physical inactivity (lead to muscle loss)

Unhealthy behaviors

Malnutrition + nutritional deficiencies :

cost of care in BPJS12

Outline presentation

Malnutrition , impact on Hospitalized patients

Nutrition screening :

BMI and

Low Lean Mass

Recent criteria / recommendation

• BEYOND BMI

Screening tools

Common tools for screening:

• Height or length

• Weight

• Arm and Head circumferences

• Waist circumference

• Elbow breadth

• Triceps skin-folds thickness

• Body mass index ( most common)

Body Mass Index (BMI)

• Practical marker of optimal weight for height and indicator of obesity or under nutrition

• Formula

BMI = Weight (Kg) : Height m2 – metric

BMI Weight status

< 18.5 Under weight

18.5 – 24.9 Normal

25 - 29.9 Over weight

> 30 Obesity

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Is BMI a reliable tool?

Vandewoude, M.F. Personal communication, 2014.

Age 75 31

Weight 56 56

Height 132 157

BMI 32.1 22.7

To screen malnutrition:

Lean body mass

• Lean body mass (LBM) is a component of body composition, calculated by subtracting body fat weight from total body weight: total body weight is lean plus fat.

• In equations:

LBM = BW − BF Lean body mass equals body weight minus body fat

LBM + BF = BW Lean body mass plus body fat equals body weight

Estimation of Lean body mass

Many mathematic formula

• For men: LBM = (0.407 × W) + (0.267 × H) − 19.2

• For women: LBM = (0.252 × W) + (0.473 × H) − 48.3

W is body weight in kilograms

H is body height in centimeters

“ clinical practice” ??

Taufiq and Syam AF et al. Journal Penyakit Dalam Indonesia 2014 ; 1(2): 108 - 113

Lower lean mass in

undernourished patients with GI

problems

24

49

.6

32

.2

6.2

39

.7

25

.2

3.5

LEAN MASS (KG) BODY CELL MASS (KG)

PHASE ANGLE

BIA RESULTS IN PATIENTS WITH GI PROBLEMS AND LIVER

DISEASES IN RSCM, JUN – DEC 2013well nourished Undernourished

Cross-sectional, retrospective study in 56 hospitalized patients in internal Medicine Ward RSCM period of Jun-Dec2013, following SGA and body composition measurement using Bioelectric Impedance Analysis. Taufiq and Ari F Syam et al. Journal Penyakit Dalam Indonesia 2014 ; 1(2): 108 - 113

p < 0.001 p = 0.003 p < 0.001

25

26

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Low lean mass and

health outcomes

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The more muscle mass lost, the higher the risk of complications that affect recovery.

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• 1. Argiles HM, et al. JAMDA. 2016;17:789-796. 2. Demling RH. ePlasty. 2009;9:65-94.

Skrining dan re sekrining

Populasi Skrining Awal Re skrining rutin

Pasien rawat inap Dalam 24 jalam

perawatan

Seminggu sekali

Pasien rawat jalan perjumpaan awal Bila status nutrisi atau

kondisi klinis berubah

Penduduk dengan

perawatan lama

Pada saat awal atau

dalam 14 hari pertama

Sebulan sekali , atau bila

ada perubahan klinis

nyata

Individu “home care” Pada saat awal visit

nurse

Bila status nutrisi atau

kondisi klinis berubah

Individu “ community

dwelling”

Pada saat awal visit

dokter

Setidaknya setahun

sekali , sebagai bagian

asesmen geriatri

Outline presentation

Malnutrition , impact on Hospitalized patients

Nutrition screening :

BMI and

Low Lean Mass

Recent criteria / recommendation

• BEYOND BMI

Proprietary and confidential — do not distribute

Malnutrition criteria : Global Leadership Initiative on Malnutrition (GLIM)

To diagnose malnutrition at least 1 phenotypic criterion and 1 etiologic criterion should be present

*GLIM : gabungan perwakilan dari ASPEN (American Society for Parenteral and Enteral Nutrition), ESPEN (European Society for Clinical Nutrition and

Metabolism), FELANPE (Federacion Latinoamericana de Terapia Nutricional, Nutricion Clinica y Metabolismo) dan PENSA (Parenteral and Enteral

Nutrition Society of Asia).

Cederholm T, et al. Clin Nutr. 2019; 38 : 1 = 9

Malnutrition Criteria

Phenotypic criteria : Etiologic criteria:

Reduced muscle massLow BMIWeight loss (un intentionally)

Reduced intakeDiseases or inflammation

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Principles of advancing patient care

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Create institutional culture

Redefine roles to include nutrition

Recognize and diagnose all patients at risk

Implement prompt intervention + continue monitoring

Communicate nutrition care plan

Discharge nutrition care + education plan

Tappenden, 2013

Fact: nutrition improved patient outcomes

Nutrition support team, physician leadership

Use valid screening toolInclude malnutrition characteristics in MR

Principles of advancing patient care

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Communicate nutrition care planDischarge nutrition care +

education planMonito0r regulary

Recognize and diagnose all patients at risk

Implement prompt intervention + continue monitoring

Communicate nutrition care plan

Create institutional culture

Redefine roles to include nutrition

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