by Mary Ellen Posthauer RDN, CD, LD, FAND
We have all heard the terms Marasmus and Kwashiorkor used to classify malnutrition that stems from the classic 1974 The Skeleton in the Closet article. Current research on this topic led to the collaboration and 2012 publication of a consensus statement of the Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.): Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition).
When treating individuals with wounds, it is critical to identify malnutrition early since a deficiency of calories and protein needed for tissue repair hampers healing. Adult malnutrition usually occurs along a continuum of either decreased intake, increased requirements or impaired nutrient absorption or utilization. Weight loss frequently occurs at some point along the way. The effects of trauma, stress, infection and disease are contributing factors for diagnosing malnutrition. Inflammation has been identified as an underlying factor that not only increases the risk of malnutrition but also contributes to the reduced response to nutrition interventions.
The Academy and A.S.P.E.N. adopted patient-specific definitions based on etiologies including social and environmental circumstances, chronic and acute illness. The first priority is to define nutritional risk by identification of two or more of these characteristics:
- Insufficient energy intake
- Weight loss
- Loss of muscle mass
- Loss of subcutaneous fat
- Localized or generalized fluid accumulation, which masks weight loss and
- Diminished functional status as measured by hand grip strength
The next step is to distinguish between chronic-disease related malnutrition and acute disease or injury-related malnutrition. The National Center for Health Statistics defines "chronic" as a condition or disease that lasts 3 months or longer. The Consensus Statement etiology-based definitions consider both time and degree of the inflammatory response. Inflammation is mediated by the immune system producing cytokines, interleukin-6, interleukin-1 and tumor necrosis factor act in response to injury or illness and can interfere with the healing process. Examples of chronic diseases resulting from persistent inflammation include diabetes, arthritis, cardiovascular disease or cancer. Individuals with wounds often have one or more of these diseases. Injury-related or acute diseases with marked inflammation include trauma, burns, sepsis, and closed head injuries. Previously we have used acute-phase proteins such as albumin and pre-albumin as primary markers for diagnosing malnutrition. However, the current body of research indicates that acute-phase proteins reflect the severity of the inflammatory response rather than nutritional status. The significance of biochemical tests using acute-phase proteins as an indicator for malnutrition is limited.
Next month I will use the characteristics in a case study to define malnutrition.
About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Panel and the American Dietetic Association’s Unintentional Weight Loss work group.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.