Ainsley Malone

Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition)

The Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommend that a standardized set of diagnostic characteristics be used to identify and document adult malnutrition in routine clinical practice. An etiologically based diagnostic nomenclature that incorporates a current understanding of the role of the inflammatory response on malnutritions incidence, progression, and resolution is proposed. Universal use of a single set of diagnostic characteristics will facilitate malnutritions recognition, contribute to more valid estimates of its prevalence and incidence, guide interventions, and influence expected outcomes. This standardized approach will also help to more accurately predict the human and financial burdens and costs associated with malnutritions prevention and treatment and further ensure the provision of high-quality, cost-effective nutrition care.

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)

The Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommend that a standardized set of diagnostic characteristics be used to identify and document adult malnutrition in routine clinical practice. An etiologically based diagnostic nomenclature that incorporates a current understanding of the role of the inflammatory response on malnutritions incidence, progression, and resolution is proposed. Universal use of a single set of diagnostic characteristics will facilitate malnutritions recognition, contribute to more valid estimates of its prevalence and incidence, guide interventions, and influence expected outcomes. This standardized approach will also help to more accurately predict the human and financial burdens and costs associated with malnutritions prevention and treatment, and further ensure the provision of high quality, cost effective nutritional care.

Defining Pediatric Malnutrition A Paradigm Shift Toward Etiology-Related Definitions

Lack of a uniform definition is responsible for underrecognition of the prevalence of malnutrition and its impact on outcomes in children. A pediatric malnutrition definitions workgroup reviewed existing pediatric age group English-language literature from 1955 to 2011, for relevant references related to 5 domains of the definition of malnutrition that were a priori identified: anthropometric parameters, growth, chronicity of malnutrition, etiology and pathogenesis, and developmental/ functional outcomes. Based on available evidence and an iterative process to arrive at multidisciplinary consensus in the group, these domains were included in the overall construct of a new definition. Pediatric malnutrition (undernutrition) is defined as an imbalance between nutrient requirements and intake that results in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other relevant outcomes. A summary of the literature is presented and a new classification scheme is proposed that incorporates chronicity, etiology, mechanisms of nutrient imbalance, severity of malnutrition, and its impact on outcomes. Based on its etiology, malnutrition is either illness related (secondary to 1 or more diseases/injury) or non-illness related, (caused by environmental/behavioral factors), or both. Future research must focus on the relationship between inflammation and illness-related malnutrition. We anticipate that the definition of malnutrition will continue to evolve with improved understanding of the processes that lead to and complicate the treatment of this condition. A uniform definition should permit future research to focus on the impact of pediatric malnutrition on functional outcomes and help solidify the scientific basis for evidence-based nutrition practices.

ESPEN guidelines on definitions and terminology of clinical nutrition

BACKGROUND A lack of agreement on definitions and terminology used for nutrition-related concepts and procedures limits the development of clinical nutrition practice and research. OBJECTIVE This initiative aimed to reach a consensus for terminology for core nutritional concepts and procedures. METHODS The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed a consensus group of clinical scientists to perform a modified Delphi process that encompassed e-mail communication, face-to-face meetings, in-group ballots and an electronic ESPEN membership Delphi round. RESULTS Five key areas related to clinical nutrition were identified: concepts; procedures; organisation; delivery; and products. One core concept of clinical nutrition is malnutrition/undernutrition, which includes disease-related malnutrition (DRM) with (eq. cachexia) and without inflammation, and malnutrition/undernutrition without disease, e.g. hunger-related malnutrition. Over-nutrition (overweight and obesity) is another core concept. Sarcopenia and frailty were agreed to be separate conditions often associated with malnutrition. Examples of nutritional procedures identified include screening for subjects at nutritional risk followed by a complete nutritional assessment. Hospital and care facility catering are the basic organizational forms for providing nutrition. Oral nutritional supplementation is the preferred way of nutrition therapy but if inadequate then other forms of medical nutrition therapy, i.e. enteral tube feeding and parenteral (intravenous) nutrition, becomes the major way of nutrient delivery. CONCLUSION An agreement of basic nutritional terminology to be used in clinical practice, research, and the ESPEN guideline developments has been established. This terminology consensus may help to support future global consensus efforts and updates of classification systems such as the International Classification of Disease (ICD). The continuous growth of knowledge in all areas addressed in this statement will provide the foundation for future revisions.

Malnutrition Diagnoses in Hospitalized Patients United States, 2010

Malnutrition is common among hospitalized patients in the United States, and its coded prevalence is increasing. Malnutrition is known to be associated with increased morbidity, mortality and healthcare costs. Although national data indicate that the number of malnutrition diagnoses among hospital discharges has been steadily rising, an in-depth examination of the demographic and clinical characteristics of these patients has not been conducted. We examined data from the 2010 Healthcare Cost and Utilization Project (HCUP), the most recent nationally-representative data describing U.S. hospital discharges. Using ICD-9 codes, we constructed a composite variable indicating a diagnosis of malnutrition. Based on our definition, 3.2% of all U.S. hospital discharges in 2010 had this diagnosis. Relative to patients without a malnutrition diagnosis, those with the diagnosis were older, had longer lengths of stay and incurred higher costs. These patients were more likely to have 27 of 29 comorbidities assessed in HCUP. Finally, discharge to home care was twice as common among malnourished patients, and a discharge of death was more than 5 times as common among patients with a malnutrition diagnosis. Taken together, these nationally representative, cross-sectional data indicate that hospitalized patients discharged with a diagnosis of malnutrition are older and sicker and their inpatient care is more expensive than their counterparts without this diagnosis.

A.S.P.E.N. Statement on Parenteral Nutrition Standardization

In response to questions regarding use of stan- dardized parenteral nutrition (PN) formulations, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) devel- oped a Task Force to address some of these issues. A.S.P.E.N. envisions standardized PN as a broader issue rather than simply using a standardized, commercially available PN product. A stan- dardized process for PN must be explored in order to improve patient safety and clinical appropriateness, and to maximize resource efficiency. A standardized process may include use of standardized PN formulations (including standardized, commer- cial PN products) but also includes aspects of ordering, labeling, screening, compounding, and administration of PN. A safe PN system must exist which minimizes procedural incidents and maximizes the ability to meet individual patient requirements. Using clinicians with nutrition support therapy expertise will contribute to that safe PN system. The purpose of this statement is to present the published literature associated with standardized PN formulations, to provide recommendations, and to identify areas in need of future research. ( Journal of Parenteral and Enteral Nutrition 31:441-448, 2007)

Nutrition Screening and Assessment in Hospitalized Patients A Survey of Current Practice in the United States

Background: The Joint Commission has mandated universal screening and assessment of hospitalized patients for malnutrition since 1995. Although various validated and nonvalidated tools are available, implementation of this mandate has not been well characterized. We report results of a survey of hospital-based professionals in the United States describing their perspective on the current range of nutrition screening and assessment practices as well as associated gaps in knowledge. Methods and Materials: Data from a 2012-2013 cross-sectional, web-based survey targeting members of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), the Academy of Medical-Surgical Nurses, and the Society of Hospital Medicine were collected with non-hospital-based members excluded. Descriptive statistical analysis was performed. Results: Survey data from 1777 unique email addresses are included in this report. A majority of respondents were dietitians, nearly half were A.S.P.E.N. members, and 69.4% reported caring for a mix of adult and pediatric patients. Most respondents answered affirmatively about nutrition screening being performed in alignment with The Joint Commission mandate, but only 50% were familiar with the 2012 Consensus Statement from the Academy of Nutrition and Dietetics/A.S.P.E.N. on adult malnutrition. In most cases, nurses were primarily responsible for nutrition screening, while dietitians had primary responsibility for assessment. No one specific assessment tool or International Classification of Diseases, Ninth Revision code was identified as being used a majority of the time in assessing or coding a patient for malnutrition. Conclusions: The survey findings affirmed compliance with accreditation standards in completing a nutrition screen within 24 hours of admission, and most hospitals appear to have a process to perform a nutrition assessment once a screen is completed. However, there is considerable heterogeneity in both use of tools and mechanisms for coding capture. Opportunities exist to improve education around nutrition screening and assessment and to identify ideal practices for these processes in hospitalized patients.

American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and American Dietetic Association (ADA): Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Nutrition Support

Joint Standards Task Force of A.S.P.E.N. and the American Dietetic Association Dietitians in Nutrition Support Dietetic Practice Group: Mary Russell, MS, RD, LDN, CNSD and Marsha Stieber, MSA, RD, CNSD: Cochairs; Susan Brantley, MS, RD, LDN, CNSD; Amy M. Freeman, RD, LD/N, CNSD; Jennifer Lefton, MS, RD, CNSD; Ainsley M. Malone, MS, RD, LD, CNSD; Susan Roberts, MS, RD, LD, CNSD; Janet Skates, MS, RD, LDN, CNSD, FADA; Lorraine S. Young, MS, RD, LDN, CNSD A.S.P.E.N. Board of Directors and ADA Quality Management Committee

When Is Parenteral Nutrition Appropriate

Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.

Methods of assessing energy expenditure in the intensive care unit.

An essential component in developing the nutrition support plan for hospitalized patients is evaluating energy requirements. Assessing energy expenditure (EE) and identifying requirements in the critically ill patient present the clinician with a challenge; how to prevent overfeeding and minimize underfeeding? Both under- and overfeeding have been associated with increased morbidity and mortality. It is known that critical illness alters EE. This alteration is hormonally mediated and is characterized by changes in metabolic processes. Methods used by clinicians to assess EE in the critically ill patient vary significantly. It is the purpose of this review to outline the various methods for evaluating EE in critical illness with emphasis on their benefits and limitations.