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5 Things Practitioners Need to Know About Malnutrition

Malnutrition is an often-unrecognized condition that is gaining global attention in the quest to improve health outcomes and reduce healthcare spending. It’s important for healthcare practitioners to know the current thinking and professional standards related to malnutrition so they can better identify it and intervene as soon as possible. Here are the 5 things that healthcare practitioners need to know about malnutrition.

  1. Malnutrition is hidden in plain sight and has serious consequences.

Malnutrition is considered a risk factor for 30% -50% of adult patients who are hospitalized;1 Although malnutrition can occur at any age, it is especially prevalent in older adults, particularly those in health care settings and those over 85 years of age.3 About 60% of older adults in hospitals and 35% to 85% of older residents in long-term care facilities are malnourished.4

It is being said that malnutrition is hidden in plain sight since its symptoms can be mistaken for other conditions and screening for malnutrition has not been widely used.1 It’s important to identify and treat malnutrition as soon as possible, as it can have serious consequences.2 Malnutrition has been linked to many adverse outcomes, including5:

  • Longer hospital stays
  • Higher probability for hospital readmission
  • Increased risk of complications (e.g., infections)
  • Higher use of resources
  • Increase in cost of care
  • Higher mortality rates
  1. Malnutrition has been formally defined and the presence of inflammation influences severity

There has been an effort to develop a single, universally accepted approach to the diagnosis and documentation of adult malnutrition and several worldwide organizations are involved in this endeavor. In the United States, these organizations include the Academy of Nutrition and Dietetics (Academy) and The American Society for Parenteral and Enteral Nutrition (ASPEN).

Definition of Adult Malnutrition

The joint statement of the Academy and ASPEN define malnutrition as‌:

“An acute, subacute, or chronic state of nutrition, in which a combination of varying degrees of overnutrition or undernutrition with or without inflammatory activity, have led to a change in body composition and diminished function.” 6  

The organizations explain that because there is no single criterion that defines malnutrition, it is recommended that practitioners assess these six parameters to determine a diagnosis; identification of two of the six shows malnutrition:6

  1. Insufficient energy consumption
  2. Involuntary weight loss
  3. Loss of muscle mass
  4. Loss of subcutaneous fat
  5. Fluid accumulation (e.g., generalized or localized)
  6. Diminished functional status (i.e., reduced hand grip strength)

Assessing the Severity of Malnutrition

The Academy and ASPEN have defined adult malnutrition in the context of inflammation because inflammation is increasingly identified as a factor that increases malnutrition risk and may contribute to diminished response to nutrition intervention and poor health outcomes. This etiology-based approach to the diagnosis of adult malnutrition in clinical settings describes malnutrition as follows:6

  • No inflammation present: Starvation-Related Malnutrition
  • Mild to moderate malnutrition (organ failure, cancer, rheumatoid arthritis, sarcopenic obesity): Chronic Disease-Related Malnutrition
  • Marked Inflammatory Response: (major infection, burns, trauma, closed head injury) Acute Disease or Injury-Related Malnutrition.

Clinical Characteristics of Severe and Non-Severe Malnutrition

The following tables outline clinical characteristics that support a diagnosis of moderate and severe malnutrition using the Academy/ASPEN criteria.6 There is insufficient clinical research data to further differentiate between mild and moderate malnutrition.

The Academy and ASPEN note that these standards are considered an evolving guide that will continue undergoing revisions. Practitioners should expect to see future changes in the parameters used to define characteristics, as new clinical research studies are available, and updates are made.6

Serum Albumin and Prealbumin as Nutritional Markers

When considering malnutrition diagnostic measures, it’s important to note that although in the past, abnormal serum albumin and prealbumin levels have been used as an indicator of protein deficiency, these parameters no longer define malnutrition. Factors that influence these diagnostic criteria include: 7

  • Clinical research studies show that serum albumin and prealbumin are not indicative of total muscle mass or total body protein and should not be used as nutrition markers.
  • Serum albumin and prealbumin levels decline when inflammation occurs, regardless of the person’s nutritional status.
  • A deficiency in serum albumin and prealbumin indicates inflammatory markers linked with “nutritional risk, “in the context of nutrition assessment instead of malnutrition.
  • Normalization of albumin and prealbumin levels may indicate a resolution in inflammation and nutrition risk and a reduction in protein and calorie requirements.
  1. The causes, symptoms and outcomes of sarcopenia are linked with malnutrition.

Sarcopenia is a syndrome of symptoms related to skeletal muscle that primarily impacts older adults. It is also linked with specific conditions such as inflammatory diseases that may occur in younger people.8 Sarcopenia is defined as a generalized and progressive loss of muscle mass and muscle function.9 Its primary symptoms include loss of skeletal muscle mass and muscle strength either alone or with increased fat mass.8.

Risk factors of sarcopenia include: 8

  • Age
  • Gender
  • Low level physical activity level
  • Dietary intake
  • Body Mass Index
  • Malnutrition
  • Falls
  • Frailty
  • Comorbidities such as dysphagia, inflammation, and insulin resistance

The repercussions of sarcopenia may include: 8

  • Impairment of muscle regeneration
  • Frail, overall state of health
  • Disability (i.e., physical)
  • Poor quality of life
  • Death

Treatment of sarcopenia includes: 10

  • Resistance exercise
  • High protein diet
  • Sufficient nutrition 

Sarcopenia and Obesity: Sarcopenic obesity is marked by concurrently having obesity or normal fat stores and undernutrition with muscle weakness. It involves changes in muscle composition, inflammation, and insulin resistance8. Sarcopenic obesity is linked to an increased risk of disability, cardiovascular diseases, hospitalization, and mortality compared to obese or sarcopenic older adults alone9.

  1. Sarcopenic dysphagia is often linked with oral frailty and malnutrition.

Dysphagia is difficulty in eating and swallowing where food or liquids have an impaired or prolonged transit from the oral cavity to the esophagus. Dysphagia is a risk factor for malnutrition due to reduced oral intake11. There are many causes of dysphagia including esophageal cancer, stroke, and Parkinson’s disease. Sarcopenia may also be the cause of dysphagia in older adults11.

Sarcopenic dysphagia is described as difficulty chewing and swallowing because of oral frailty or a generalized weakness of the muscles and bones involved in chewing and swallowing food. Specifically, sarcopenia can cause dysphagia through decreased tongue strength, reduced range of tongue motion, weakened pharyngeal muscle contraction, and deteriorated endurance of swallowing muscles11.Sarcopenic dysphagia is often associated with malnutrition and dehydration due to inadequate nutritional intake and inflammation associated with poor oral hygiene12.

The effect of sarcopenic dysphagia on nutritional status can be profound. As an individual’s ability to swallow becomes impaired, adequate dietary intake becomes a challenge, and vice versa. Therefore, early detection and management of dysphagia are critical to halting malnutrition.12

  1. Vigilance is required to regularly screen for and address malnutrition

Because of the significant detrimental consequences of malnutrition early detection is essential especially when it signals a need for intervention before symptoms such as weight loss and poor outcomes can occur. Registered Dietitians take the lead to ensure that nutrition screening is the first step in identifying malnutrition13.

Malnutrition Screening Tools

There are several validated screening tools that can be used identify those at risk for malnutrition, these include:

  • The Malnutrition Screen Tool (MST) can be used for all populations and settings; learn how to use this tool here.
  • The Mini Nutrition Assessment is used for older adults: information about how to use this screening tool can be found here.

After screening, the registered dietitian continues the nutrition care process using nutrition-focused physical examination; nutrition diagnosis; and nutrition prescription and interventions; and develops the nutrition plan of care. Registered dietitians communicate with physicians who medically diagnose malnutrition, which may provide additional payment for implemented interventions and increased care level.13

  1. Sauer AC, Goates S, Malone A, Mogensen KM, Gewirtz G, Sulz I, Moick S, Laviano A, Hiesmayr M. Prevalence of Malnutrition Risk and the Impact of Nutrition Risk on Hospital Outcomes: Results From nutritionDay in the U.S. JPEN J Parenter Enteral Nutr. 2019 Sep;43(7):918-926. Epub 2019 Jan 22. doi: 10.1002/jpen.1499
  2. Kabashneh S, Alkassis S, Shanah L, Ali H. A Complete Guide to Identify and Manage Malnutrition in Hospitalized Patients. Cureus. 2020 Jun 7;12(6):e8486. doi: 10.7759/cureus.8486. PMID: 32656004; PMCID: PMC7343301.
  3. Norman K, Haß U, Pirlich M. Malnutrition in Older Adults-Recent Advances and Remaining Challenges. Nutrients. 2021;13(8):2764. Published 2021 Aug 12. doi:10.3390/nu13082764
  4. Barrett ML, Bailey MK, Owens PL. Non-maternal and Non-neonatal Inpatient Stays in the United States Involving Malnutrition, 2016. U.S. Agency for Healthcare Research and Quality. accessed 7/25/22
  5. Ruiz AJ, Buitrago G, Rodríguez N, Gómez G, Sulo S, Gómez C, Partridge J, Misas J, Dennis R, Alba MJ, Chaves-Santiago W, Araque C. Clinical and economic outcomes associated with malnutrition in hospitalized patients. Clin Nutr. 2019 Jun;38(3):1310-1316. doi: 10.1016/j.clnu.2018.05.016. Epub 2018 Jun 1. PMID: 29891224.
  6. White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). Journal of the Academy of Nutrition and Dietetics. 2012;112(5):730-738. doi:10.1016/j.jand.2012.03.012
  7. Evans DC, Corkins MR, Malone A, Miller S, Mogensen KM, Guenter P, Jensen GL; ASPEN Malnutrition Committee. The Use of Visceral Proteins as Nutrition Markers: An ASPEN Position Paper. Nutr Clin Pract. 2021 Feb;36(1):22-28. doi: 10.1002/ncp.10588. Epub 2020 Oct 30. Erratum in: Nutr Clin Pract. 2021 Aug;36(4):909. PMID: 33125793.
  8. Cruz-Jentoft AJ,-, Bahat G, Bauer J, Boirie Y, Bruyère O, et al, Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2, Sarcopenia: revised European consensus on definition and diagnosis, Age and Ageing, Volume 48, Issue 1, January 2019, Pages 16–31,
  9. Therakomen V, Petchlorlian A, Lakananurak N. Prevalence and risk factors of primary sarcopenia in community-dwelling outpatient elderly: a cross-sectional study. Sci Rep. 2020;10(1):19551. Published 2020 Nov 11. doi:10.1038/s41598-020-75250-y
  10. Agostini F; Bernett, A; Di Giacomo G; Viva M; Paoloni M; Mangone M; Santilli V; MasierovS, Rehabilitative Good Practices in the Treatment of Sarcopenia, American Journal of Physical Medicine & Rehabilitation: March 2021 – Volume 100 – Issue 3 – p 280-287 doi: 10.1097/PHM.0000000000001572.
  11. Dellis S, Papadopoulou S, Krikonis K, Zigras F. Sarcopenic Dysphagia. A Narrative Review. J Frailty Sarcopenia Falls. 2018;3(1):1-7. Published 2018 Mar 1. doi:10.22540/JFSF-03-001
  12. de Sire, A.; Ferrillo, M., Lippi, L.; Agostini, F.; de Sire, R.; Ferrara, P.E.; Raguso, G.; Riso, S.; Roccuzzo, A.; Ronconi, G.; et al. Sarcopenic Dysphagia, Malnutrition, and Oral Frailty in Elderly: A Comprehensive Review. Nutrients 2022, 14, 982.
  13. Khan M, Hui K, McCauley SM. What is a registered dietitian nutritionist’s role in addressing malnutrition? Journal of the Academy of Nutrition and Dietetics. 2018;118(9):1804. doi:10.1016/j.jand.2018.06.013

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