Malnutrition: - PowerPoint Presentation

Slide1

Malnutrition: Definition, Prevalence, Outcomes, and CostSlide2

What is Malnutrition?

Malnutrition = “undernutrition”

Inadequate intake of energy, protein and other nutrients

Obese malnourished: excess fat stores but micronutrient or macronutrient (typically protein) malnourishedSustained inadequate intake leads to functional change in tissues of the body e.g. muscle loss, weakness, immune function, capacity for recovery, cognitionResponds to re-feedingInflammation (disease) can influence response to re-feeding

CMTF website adapted from: AW

McKinlay

: Malnutrition: the

spectre

at the feast.

J R

Coll

Physicians

Edinb

2008:38317–21.Slide3

Diagnosing Malnutrition

Subjective global assessment (SGA)

is the gold standard for diagnosing malnutrition in hospital.

Classification: A: Well nourished: no history or physical findings of malnutritionB: Moderately malnourished: Weight loss 5-10% of usual body weight; unintentional weight loss (6 months); mild/moderate signs of malnutrition

C: Severely Malnourished:

Unintentional weight loss > 10% usual body weight (past 6 months); severe signs of malnutrition

*

SGA specifically assesses for protein-energy malnutrition and not micronutrient malnutritionSlide4

Malnutrition

Morbidity



Wound healing Infections Complications Convalescence

Mortality



Treatment



Length of Stay



COSTS



Quality of Life

Suffering

Slide5

Human Costs of Malnutrition

Negative outcomes associated with malnutrition

Delayed wound healing

Impaired immunity Lower quality of life

Impaired function

Increased length of stay, readmission, mortality and/or morbidity rates

Correia M.I. Et al:

Clin

Nutr

.

2003; 22:235-9.;

Covinsky

K.E. et al:

J Am

Geriatr

Soc

. 2002; 50:631-7.;

Middleton M.H. et al:. Intern Med J 2001;31:455-61.;

Ferguson M. et al. J Am Diet Assoc 1998;98 (suppl.): A22

. Suominen M et al

. Eur J Clin

Nutr 2005; 59: 578-583.;

Neumann SA et al. J Hum Nutr

Dietet 2005; 18: 129-136.; Norman K et al. World J Gastroenterol

2006; 12: 3380-3385.; Pauly L et al. Z

Gerontol

Geriatr

2007; 40: 3-12.; Keller H, Can J Rehab 1997; 10(3): 193-204; Keller H, J Nutr Elder 1997;17(2):1-13.Slide6

Cederholm

T et al.

Am J Med.

1995

;

98:67-74.

Increased Mortality

44% mortality

in malnourished patients after 9 months vs.

18%

in well-nourished patients

Months After Hospitalization

%

Mortality

0

10

20

30

40

50

0

1

2

3

4

5

6

7

8

9

PEM

non-PEM

PEM: Protein Energy MalnutritionSlide7

The Costs Associated with Malnutrition

Malnutrition at admission extends length of stay by ~3 days = $1500-2000 CAD / patient

(Curtis et al, 2016)

Admitted malnourished patients…Cost ~60% more than well nourished patients (Braunsweig et al, 2000; Correira et al, 2003)This cost is independent of disease state (Lim et al., 2012)Length of stay (LOS) 2-6 day longer

(

Correira

et al., 2003; Kyle et al., 2004;

Pirlich

et al., 2004)

Developing malnutrition during hospitalization results in even longer LOS ~15 d

(Álvarex-Hernández et al., 2012)2 x increased risk of readmission in 2 weeks

(Lim et al., 2012)Increased two-year mortality 7 fold (Lim et al., 2012)Slide8

Length of Stay and ReadmissionBeing severely malnourished (SGA C), low hand grip strength (HGS) and reduced food intake during the first week of hospitalization independently predicted a longer length of stay

SGA C and HGS were independent predictors of 30-day readmission

Jeejeebhoy

KN, 2015 AJCN Slide9

Is Treatment Effective?

Generic Oral Nutritional Supplementation(ONS)

(

Phillipson et al., 2013)1.6% of 44 million hospital visits used ONSONS use decreased LOS by 21%; ~$ 4734 USD/patient savings Scoping review: food first interventions (Cheung et al., 2013)Individualized RD treatment  improved intake and health outcomes

protected mealtimes, eating assistance

 improves food intake

Implementation of guidelines in ICU

(

Doig

et al., 2008; Martin et al., 2004)

Early nutrition support

improves outcomesSlide10

Malnutrition Research in Canada

The Canadian Malnutrition Task Force (CMTF) conducted the Nutrition Care in Canadian Hospitals (NCCH) cohort study (2010-2013).

The NCCH study provides

evidence to support best practice for prevention, identification and treatment of malnutrition in hospitals from 18 hospitals across Canada. Many of the results shown in this presentation are from the NCCH study. Slide11

Hospital Malnutrition in Canada

Almost 1 in 2 medical or surgical patients who stay 2+ days are malnourished at admission

(Allard et al., 2015)

Less than ¼ of patients see a dietitian, most of these patients are not malnourished; 75% of malnourished are missed (Keller et al., 2015)Patients who deteriorate have a longer length of stay (medical 18 days; surgical 12 days) (Allard et al., 2016)2/3 of patients leave in the same nutritional state as admitted while 1 in 5 gets worse (Allard et al., 2016)Slide12

Hospital Malnutrition in Canada

Poor food intake (≤50% of tray) in the first week of hospital stay occurs for ~35% of patients

(Allard et al., 2015)

Poor food intake during admission predicts length of stay when adjusted for other covariates such as malnutrition at admission (Allard et al., 2015)Patients experience many barriers to intake (Keller et al., 2015)42% interrupted during meal69% if missed a meal, not provided food30% couldn’t open food packages20% could not reach meal traySlide13

Prevalence of Malnutrition in Hospital

Reported prevalence of malnutrition among hospitals in North America and Europe:

20% to 60%.

The prevalence of malnutrition at admission is reported at 45% in acute care hospitals in Canada (Allard et al, JPEN 2015).

Prevalence based on SGA

(

Based on Nutrition Care in Canadian Hospitals Study)Slide14

What predicts length of stay?(Nutrition Care in Canadian Hospitals Study, Allard et al., JPEN 2015)

Characteristics

Hazard Ratio

95% CI

SGA* B/C

0.73

0.62, 0.86

Hand grip strength

1.12

1.01, 1.23

Nutrition support

0.61

0.42, 0.88Food intake ≤50%

0.730.62, 0.87

Male0.770.63, 0.93Lives in “other” setting

0.720.53, 0.96

Number of diagnoses23

0.700.580.59, 0.840.44, 0.76

Number of meds0.96

0.95, 0.98

HR > 1.0 characteristic predicted shorter length of stay HR < 1.0 predicted a longer length of stay. Adjusted for: cancer, type of unit, CCI, education, age, RD visit, NPO for 3+ d, preadmission wt loss, BMI at admission

All of these factors, except a higher hand grip strength,

predict a longer length of stay.

This means that malnutrition (SGA B/C),

taking into account diagnoses, age and other covariates adjusted for in this analysis, predicts length of stay.

Food intake regardless of nutritional status also predicts length of stay

when adjusting for covariates including nutritional status.

Slide15

Change in Nutritional Status and Length of Stay

SGA

Stable

Deteriorated

Improved

Well nourished

9

d

10

d

N/A

Mild/mod

mal’n9.5 d21 d10.5 d

Severe mal’n12.5 d

N/A12.0 d

(Nutrition Care in Canadian Hospitals Study, Allard et al. Clin

Nutr 2015)(Admission vs. Discharge n=409 who stayed 7+ days)Slide16

Summary

Prevalence of malnutrition in medical and surgical patients who stay 2+ days in Canadian hospitals is 45%

Nutritional status deteriorates in hospital for some

Food intake ≤ 50% and malnutrition are key predictors of length of stayMalnutrition is costly in human and financial termsA malnourished patient costs $1500-2000 CAD moreTreatment improves outcomesSlide17

Moving Forward…All health care professionals need to be concerned about the nutritional status of patients

All health care professionals need to…

Become

“Food Aware” Recognize that “Food is Medicine. Medicine Heals.”Slide18

Acknowledgements

These slides were created and approved by:

Heather Keller

Celia Laur

Bridget Davidson

The More-2-Eat Education Group*

* Includes input from the UK Need for Nutrition Education/Innovation

Programme

(

NNEdPro

) Group

This research is funded by Canadian Frailty Network (known previously as Technology Evaluation in the Elderly Network, TVN), supported by Government of Canada through Networks of

Centres of Excellence (NCE) Program