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nutrition issues in gastroenterology series 8 series editor carol rees parrish m s r d cnsd nutritional assessment current concepts and guidelines for the busy physician david s seres malnutrition ...

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                        NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #8
                        Series Editor: Carol Rees Parrish, M.S., R.D., CNSD
                     Nutritional Assessment: Current
                     Concepts and Guidelines for the
                     Busy Physician
                     David S. Seres
                     Malnutrition is associated with a great deal of morbidity. The prevention of mal-
                     nourishment with early intervention is much more effective in improving outcome
                     than is reacting once a patient has become ill and has obvious nutritional deficits. It
                     is not difficult to become proficient at screening patients for nutritional risk as most
                     of the information that is used in the nutritional assessment is already being gathered
                     in the clinical setting. It is important to distinguish between the effects of improper
                     nourishment and the effects of catabolic disease when assessing nutritional status.
                     The basics of nutrition assessment for the practicing clinician and the pathophysiol-
                     ogy of the different states of malnutrition are reviewed.
        INTRODUCTION                                               physicians pay far too little attention and are poorly
             he importance of appropriate nutritional assess-      trained in assessing our patients and screening for
             ment cannot be understated. It has even been          nutritional risk. Compounding our inadequate educa-
        Tsaid that altered nutritional markers can account         tion is a lack of agreement between different disci-
        for 50% of the variance in response to any given ther-     plines as to how to refer to nutritional markers and
        apy. Despite the impact that the underlying nutritional    states of malnutrition, and the mistaken identification
        state has on prognosis and outcome, however, we as         of markers of dysmetabolism as reflective of nutri-
                                                                   tional intake. It is the goal of this article to reintroduce
        David S. Seres, M.D., CNSP, Chair, Physician Certifi-      some of the nutritional assessment terminology, con-
        cation, National Board of Nutrition Support Certifica-     cepts, and techniques, and to review the current clini-
        tion, Clinical Instructor, Albert Einstein College of      cal understanding of these conditions. 
        Medicine, Assistant Attending Physician, Beth Israel
        Medical Center, New York, NY.                                                               (continued on page 32)
        30    PRACTICAL GASTROENTEROLOGY • AUGUST 2003
         Nutritional Assessment
         NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #8
        (continued from page 30)
            Nutritional assessment serves several goals. The           the ongoing clinical assessment of patients to make at
        most important of these is to identify patients at nutri-      least subjective assessments of the nutritional status of
        tional risk early, particularly those with systemic dis-       the patient. The good news is that this assessment can
        ease, to prevent the development of a state of nutri-          be accomplished with very little time and by using
        tional depletion or excess, both of which will adversely       skills we already possess.
        affect prognosis. The nutritional screening and evalua-
        tion process should identify those patients who may            REVISITING NUTRITIONAL TERMINOLOGY 
        benefit from nutritional interventions, including those        AND CONCEPTS
        at higher risk for responding poorly to, or developing
        complications from, medical or surgical interventions.         Malnutrition and Body Weight
        For example, a patient with cancer who is to undergo a         Malnutrition is typically associated with under-nourish-
        major surgical procedure is far more likely to develop         ment, yet it also encompasses excess nourishment and is
        wound healing problems and/or infections if they have          best defined as an imbalance between energy intake and
        lost a significant amount of weight prior to surgery (1).      utilization. Nutritional states are defined based on their
            Nutritional screening and assessment are best per-         effect on the health of the organism. Therefore, the term
        formed by a multidisciplinary team. Each member of             "nutritional risk" better serves to describe patients' states
        the medical team, the dietitian, the nurse, the pharma-        of malnutrition. For instance, medical obesity is defined
        cist, the ancillary personnel, and the physician, partic-      not based on the cosmetic effect of excess weight, but
        ipates in the processes and comes to the patient with a        on the effect of the excess weight on predicted longevity
        unique perspective and knowledge base. Physicians              or the risk for developing co-morbidities. There are con-
        are often absent from the nutrition assessment process,        ventions by which these conditions are defined, based
        for a number of reasons and in response to a multitude         either on a one-time assessment, or based on changes in
        of seemingly more urgent pressures. But, as long as            weight over time (2). 
        physicians are the final decision makers where patient             A person may be deemed malnourished based on a
        care is concerned, we must be at least cognizant of the        stable weight below normal, due to a loss of an arbi-
        patient's nutritional state, as it will affect the entire      trary amount of weight, or due to a loss of a significant
        course of the patient's illness and response to our ther-      percentage of baseline weight. Commonly, the appro-
        apeutic interventions. Further, the physician is the con-      priateness of a given weight for an individual is deter-
        tinuous link between the patient and the medical sys-          mined relative to their height. Ideal weight is deter-
        tem and will be the one tracking the patient's course.         mined by insurance companies based on longevity and
            Whether or not the patient has access to all mem-          is available on published tables. The Body Mass Index
        bers of the "nutrition team" will depend on the setting                                               2
                                                                       (BMI) is determined as weight/height (3) See Table 1;
        in which the patient is being treated. The dietitian is        also go to: http://nhlbisupport.com/bmi/bmicalc.htm
        most often the focal person in assessing patients in the       (4) for easy calculation. 
        hospital, but is too frequently excluded from the eval-            A BMI of 20 to 25 is deemed normal. Most guide-
        uation of patients with chronic disease in the outpatient      lines identify patients at nutritional risk if they are:
        or home environment. The nurse is often the main               • <80% of ideal weight,
        source of information on the patient's intake and social       • Have a body mass index less than 20,
        history in the hospital, long-term care, or home envi-         • Have lost 5% of baseline or 5 pounds in one month,
        ronment, but in the office setting is often busy with          or
        other tasks that preclude this kind of information gath-       • Have lost 10 pounds or 10% of usual body weight in
        ering. The patient's relationship with the outpatient          6 months. 
        pharmacist is severely limited by the pressures of the         When reporting under- or over-nourishment as a risk
        high volume of business required in the current man-           factor, it should be made clear in the assessment
        aged care environment. It falls, then, on the shoulders        whether the determination was made based on a single
        of the physician, or physician extender, to find time in                                          (continued on page 34)
        32    PRACTICAL GASTROENTEROLOGY • AUGUST 2003
          Nutritional Assessment
          NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #8
         (continued from page 32)
          Table 1                                                            Table 2 
          Body Mass Index (BMI) (3)                                          Evaluation of Recent Weight Change (5)
                                     weight (kg)                                                        UBW – current weight × 100 
                             BMI = —————                                      Recent weight change = ————————————
                                               2                                                                      UBW
                                     height (m)
          OR                                                                 Time Period            Significant Loss     Severe Loss
                weight (in pounds) /height (in inches2) × 703                1 week                      1-2%                >2%
          Classification                        BMI                          1 month                      5%                >5%
                                                                             3 months                    7.5%              > 7.5%
          Severe or morbid obesity              > 40                         6 months                     10%               > 10%
          Moderate obesity                      30–40
          Mild obesity                          27.5–30                      Used with permission from the American Society for Parenteral
          Obesity                               >27.5                        and Enteral Nutrition
          Appropriate weight (19–34 yr)         19–25
          Appropriate weight (>35 yr)           21–27                       quacy of intake. This concept is quite foreign to most
          Mild malnutrition                     17–18.5                     healthcare practitioners, as we have all been taught to
          Moderate malnutrition                 16–17                       think that a reduction in serum albumin reflects a pro-
          Severe malnutrition                   <16                         tein "deficiency." Furthermore, there are a number of
          Used with permission from the American Society for Parenteral     illnesses, metabolic derangements, and therapies that
          and Enteral Nutrition                                             may affect serum albumin (Table 3) (7).
                                                                                The term kwashiorkor is often used to describe the
        measurement or based on changes over time. The                      state of dysmetabolism seen in our ill patients. The
        degree to which a given loss of weight has impact on                term actually reflects a specific syndrome that devel-
        nutritional risk is summarized in Table 2.                          ops almost exclusively in children who suddenly
             If weight loss is the determinant of malnourish-               develop hypoalbuminemia and ascites, are irritable,
        ment, we are usually concerned with unintentional loss              and have characteristic skin and hair changes. The
        (except in the case of patients with eating disorders).             occurrence of this condition is frequently associated
        What is often confusing about these defining charac-                with periods of endemic starvation, but the patients
        teristics of malnutrition is that a patient who remains             suffering from kwashiorkor do not have to be under-
        obese after losing a significant amount of weight may               nourished to develop the syndrome. Although the diet
        carry the same sort of risk profile as a chronically                was characteristically low in protein and high in car-
        undernourished patient.                                             bohydrates in the original descriptions of the syn-
                                                                            drome, patients with kwashiorkor are not necessarily
                                                                            deficient in protein in their diet. In fact, kwashiorkor
        Serum Proteins                                                      has been described in populations of breast-fed infants
        In contrast to those with pure malnutrition, patients               of adequately nourished mothers. 
        with systemic illness have an alteration in the metabo-                 The clinical syndrome of kwashiorkor is best
        lism of energy substrates (6). The term dysmetabolism               described as a state of dysmetabolism due to the misuse
        may be more appropriate to describe the "nutritional"               of protein by the body as an energy substrate instead of
        alterations seen in these patients. Hypoalbuminemia                 as a building block. The breakdown of albumin and
        and reduced prealbumin and transferrin levels in the                other serum proteins to make acute-phase reactants,
        blood are due to the effect of circulating inflammatory             and the suppression of hepatic protein synthesis may
        modulators, often occur in the face of normal or at                 also play roles. The mechanism for the development of
        least adequate nourishment, and do not reflect the ade-                                                  (continued on page 36)
         34    PRACTICAL GASTROENTEROLOGY • AUGUST 2003
           Nutritional Assessment
           NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #8
         (continued from page 34)
           Table 3                                                                out catabolic illness until the day of admission for an
           Factors Affecting Serum Albumin Levels (7)                             acute sepsis. The following day the albumin level will,
                                                                                  as often as not, be significantly decreased. Even imme-
           Increased                                                              diate nutrition support will not stop this drop in albu-
           • Dehydration                                                          min, which will continue to worsen as long as this
           • Exogenous albumin (transient)                                        patient remains septic (9). 
                                                                                       Other proteins have been proposed as markers of
           Decreased                                                              nourishment. These include prealbumin and transfer-
           • Increased intravascular volume                                       rin. Both of these proteins are reverse acute-phase
              – Overhydration                                                     reactants. This means that serum concentrations of
              – Eclampsia                                                         these proteins drop during states of inflammation, as
           • Inflammatory states                                                  does albumin. Prealbumin, in particular, has become a
              – Infection                                                         popular "marker" for assessing the nutritional state of
              – Catabolic stress
              – Trauma/post-operative states                                      our patients. Unlike albumin, which may take six
              – Burns                                                             weeks to normalize, prealbumin has a half-life of 48-
              – Collagen vascular diseases                                        72 hours and may normalize within a week once the
              – Cancer                                                            inflammation has resolved. While normalization indi-
           • Hepatic failure                                                      cates an improvement in risk, it may occur whether
           • Protein losing states                                                intake is adequate or inadequate and does not, there-
              – Nephrotic syndrome                                                fore, reflect nutritional adequacy. Levels of both preal-
              – Enteropathies                                                     bumin and transferrin are affected by numerous factors
           • Kwashiorkor                                                          in addition to inflammation. Both are increased in
           • Corticosteroid use                                                   advanced renal disease and by use of oral contracep-
           Adapted and used with permission from the University of                tives. Transferrin is increased in iron deficiency and
           Virginia Health System Nutrition Support Traineeship Syllabus          decreased in non-iron deficient anemias. Prealbumin
                                                                                  levels are increased and transferrin levels decreased
                                                                                  when corticosteroids are administered (10).
         hypoalbuminemia is likely the same for most patients                          Catabolism, and not inadequate intake, is the real
         with systemic illness as it is in patients with kwash-                   challenge to our patients and to our ability to provide
         iorkor, that is, due to inflammation and not due to inad-                appropriate nourishment. As suggested above, the
         equate protein intake. Because the syndrome of kwash-                    nutritional result of catabolism is an alteration in
         iorkor is distinct, the term should not be applied                       energy metabolism. In the normal human, carbohydrate
         broadly to hypoalbuminemic patients. "Hypoalbumine-                      and fat are the preferred energy sources. In the stressed
         mia of catabolism" would better describe the hypoalbu-                   individual, inflammatory cascades are activated that
         minemic patients with systemic illness (8).                              wholly alter the use of substrates. Fat enters futile
              Whether we are discussing kwashiorkor or the                        cycling, insulin resistance and other mechanisms shunt
         hypoalbuminemia of catabolism, it has become quite                       carbohydrate away from normal energy forming mech-
         clear that, while both are states of nutritional risk, nei-              anisms, and protein becomes a preferred energy fuel.
         ther of these states of malnutrition is due solely to mal-               While we can assuredly provide patients with excess
         nourishment. Many studies and years of clinical expe-                    nourishment, either by enteral or parenteral routes, the
         rience have shown us that undernourished patients do                     substrates will not be put to their normal uses (6). 
         not become hypoalbuminemic until, and unless, they                            By identifying a patient as being at nutritional risk,
         become ill. Additionally, ill patients may become                        we hope to intervene, or to refer patients to a nutrition
         hypoalbuminemic without being malnourished. Take                         professional, before their nutritional risk translates into
         for instance the patient that we often see in the inten-                 systemic disease with the concurrent development of
         sive care unit. They may be obese and otherwise with-                                                             (continued on page 38)
          36     PRACTICAL GASTROENTEROLOGY • AUGUST 2003
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...Nutrition issues in gastroenterology series editor carol rees parrish m s r d cnsd nutritional assessment current concepts and guidelines for the busy physician david seres malnutrition is associated with a great deal of morbidity prevention mal nourishment early intervention much more effective improving outcome than reacting once patient has become ill obvious deficits it not difficult to proficient at screening patients risk as most information that used already being gathered clinical setting important distinguish between effects improper catabolic disease when assessing status basics practicing clinician pathophysiol ogy different states are reviewed introduction physicians pay far too little attention poorly he importance appropriate assess trained our ment cannot be understated even been compounding inadequate educa tsaid altered markers can account tion lack agreement disci variance response any given ther plines how refer apy despite impact underlying mistaken identification s...

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