novel diagnostic criteria and intervention of malnutrition ... poernomo boedi - malnutrition novel...
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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
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
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” ??
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
The more muscle mass lost, the higher the risk of complications that affect recovery.
29
• 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
38
Principles of advancing patient care
43
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
44
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