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Concurrent Session: Dialogue on implementing malnutrition diagnosis criteria; perspectives from three regions

Friday, May 6, 2016
3:30pm - 5:00pm


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Europe, the United States and Canada have identified various diagnostic criteria for malnutrition. This symposia will be focused on describing these various criteria and how they are currently being rolled out for implementation in their respective regions.

The A.S.P.E.N./Academy Malnutrition Diagnostic Criteria: Awareness, Implementation and Validation
Ainsley Malone

Malnutrition has been an important issue for A.S.P.E.N. since the early 1980's. In 1996, through its own efforts and those of other nutrition organizations, the Joint Commission for Accreditation of Hospitals added the standard that hospitals must perform nutrition screening within 24 hours of patient admission. In 2009, malnutrition became a major focus of A.S.P.E.N.'s strategic work. Recognizing the need to standardize the criteria for diagnosing malnutrition, A.S.P.E.N. collaboratively participated with the Academy of Nutrition and Dietetics to develop a consensus statement on recommended characteristics for the identification of adult and pediatric malnutrition (2012/2015). For adults, two or more of these characteristics are used to diagnose severe or moderate malnutrition: reduced nutrient intake, unintended weight loss, loss of muscle, loss of subcutaneous fat, fluid accumulation and diminished hand grip strength. For pediatric patients, weight/height, mid-upper arm circumference and body mass index z scores, weight changes and/or inadequate nutrient intake are used for a malnutrition diagnosis. Nutrition screening effectiveness is well documented however it is gaps in identifying and addressing the malnourished patient that often occur. In 2015, A.S.P.E.N. revised its adult and pediatric "nutrition care pathways" to promote best practice in malnutrition care. Malnutrition prevalence has varied over the decades ranging from 25% - 54%.; this variability is attributed to a range of nutrition assessment methodologies utilized. There is a clear need to utilize a consistent method for assessing malnutrition prevalence in the United States. A.S.P.E.N. has created an annual Malnutrition Awareness Week to bring attention to the malnutrition issue.

The ESPEN standpoint on definitions and diagnostic criteria of malnutrition
Dr. Tommy Cederholm

Professor Cederholm will present the two consensus efforts ESPEN has performed over the last three years according to (1) diagnostic criteria for malnutrition, which is now published in Clinical Nutrition (Cederholm et al. Diagnostic criteria for malnutrition - An ESPEN consensus statement. Clin Nutr 2015;34:335-40), and (2) a suggestion for aetiology-based malnutrition diagnoses that could be a basis for the revision of ICD-11 that will be presented by WHO in 2018. The latter initiative is in its final stages and not yet published. The most important concepts for this statement are disease-related malnutrition (DRM) and non-disease-related malnutrition. DRM is subdivided into inflammation-driven DRM and non-inflammation-driven DRM, whereas hunger-related malnutrition is the major non-DRM concept. ESPEN looks forward to a constructive conversation in order to reach a global consensus on these crucial topics.

A Two-Step Process for Nutrition Care using Subjective Global Assessment.
Khursheed Jeejeebhoy for the Canadian Malnutrition Task Force

The objective of assessing nutritional status in acute care is to identify an individual who needs nutritional support, its urgency and route. In order to achieve these objectives, the assessment has to evaluate, in a holistic way, nutrient intake and absorption on the one hand and requirements based on metabolic needs and effect of illness on the other. The urgency and extent of intervention is based on the trajectory of weight change and functional status. Subjective Global Assessment (SGA) is a bedside, clinically validated way of meeting these objectives. Numerous studies have shown that it identifies increased risk of complications, increased hospital stay and identification of patients responding to nutritional therapy not attained by use of anthropometrics and serum protein measurements alone. SGA is used in the Integrated Nutrition Pathway for Acute Care (INPAC) developed as a feasible pathway for nutrition care in hospital. This is an evidence-informed, consensus-based algorithm that recommends a two-step process for detection using screening and Subjective Global Assessment. Screening will result in false positives which need to be identified prior to undertaking treatment. Dietitian training to complete SGA is a key initiative of the Canadian Malnutrition Task Force. INPAC is currently being implemented in five diverse hospitals in Canada and evaluation will demonstrate resource utilization with this two-step diagnostic process.



Dr. Tommy Cederholm

Head of Clinical Nutrition and Metabolism, Department of Public Health and Caring Sciences, Uppsala University, Sweden

Ms. Ainsley Malone

Dietitian Member, Nutrition Support Team, Mt. Carmel West Hospital Columbus, Ohio

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