Assessing Malnutrition in the Adult Population: The Role of the RDN: Your Questions Answered

Over 300 participants attended this free webinar Assessing Malnutrition in the Adult Population: The Role of the RDN offered by OneOp Nutrition and Wellness Team. There was a lively discussion and many questions in the chat pod. Our presenter Julia McQueen, MPH, RD, LDN, CNSC graciously offered to answer questions that were not addressed at the webinar.

Dietitians can still earn 1.0 CPEU by watching the recording at https://oneop.org/event/116593/

Patients with paralysis – things to consider:

Do not use lower body muscle loss as this would be expected. I would note this in a nutrition assessment in a general way, i.e., “lower body muscle atrophy present though expected with paralysis.”
Upper body use/ability may vary, so understanding a patient’s functional status is necessary.
When possible, always discuss the patient’s baseline with the patient and/or family members and evaluate your findings in this context.
It may be helpful to ask questions such as “have you noticed changes to your upper body, the ways your clothes fit, what you see in the mirror” to assist in gathering a history.
If weight and appetite are stable, consider your physical findings are your patient’s baseline.

Hesitant providers –

I’m not sure if this question is regarding auditors looking at malnutrition codes or providers assigning the malnutrition code to their patients and adding it to the problem list. For provider hesitation, it may be beneficial to educate and discuss the ASPEN guidelines and, even more generally, what dietitians are assessing when considering a malnutrition diagnosis. I would recommend asking to be part of any grand rounds or provider meetings to even briefly educate and discuss this, especially if it is widespread among providers in your setting. It is not unusual to be unable to assess every point of criteria – perhaps you have a patient who is a poor historian so unable to gather a nutrition history. Still, there is strong evidence on Nutrition Focused Physical Exam (NFPE) and/or documentation of unintentional weight loss from the medical record. Essentially, if a dietitian is confident in their diagnosis, it should be taken as such. However, if a provider disagrees with the assessment, they do not have to add it to the problem list. If you are not confident yet in what you have gathered, you may be able to obtain more information available on the follow-up. This information may include being able to complete an NFPE or suspect a patient’s mental status will change so that they can participate in a discussion of their history. It is then reasonable to identify your criteria and wait until follow-up for a more firm and well-rounded diagnosis.

NFPE subjectivity

Yes, a physical assessment in general (be it dietitians, nurses, or providers) is subjective. When conducted by a clinician who has undergone training in NFPE and regular practice, it is useful information regarding a patient’s nutritional status and risk for malnutrition. Four areas of criteria for malnutrition utilize data from a physical exam, which makes it an important part of our overall assessment. Observing our patients visually and conducting a physical assessment gives us data we cannot otherwise see from their medical records. Repeating a physical exam on follow-up or with a change in medical status is also helpful in comparing previous results. It is a part of the RDN scope of practice to be able to differentiate between normal and non-normal findings on a physical exam and place that into context. Nutrition histories, diet recalls, and intake questionnaires are all subjective tools we regularly use as nutrition professionals.
To give background on the malnutrition criteria, the ASPEN/AND criteria were created in response to a change made in 2007 to the Centers for Medicare and Medicaid Services reimbursement processes to support a disease severity component, of which malnutrition was included. There was not yet, at that time, a consensus for a malnutrition diagnosis. It was recognized that a standardized approach was needed and requested by both members of ASPEN/AND and the Centers for Medicare & Medicaid Services (CMS). Validation studies are ongoing with the ASPEN criteria to answer questions specific to usability, feasibility, validity (does it measure what it is supposed to?), and reliability (is it consistent in its measurement?). These studies compare a previously validated methodology (typically validated malnutrition screening tools). Few large prospective trials have been completed. Smaller studies have shown that the ASPEN criteria has promising feasibility and usability. This continues to be an important area of study.
Validation of the Academy/A.S.P.E.N. Malnutrition Clinical Characteristics (jandonline.org)
AND/ASPEN and the GLIM malnutrition diagnostic criteria have a high degree of criterion validity and reliability for the identification of malnutrition in a hospital setting: A single‐center prospective study – El Chaar – – Journal of Parenteral and Enteral Nutrition – Wiley Online Library
Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Consensus Malnutrition Characteristics: Usability and Association With Outcomes – Mogensen – 2019 – Nutrition in Clinical Practice – Wiley Online Library

Edema

It’s important to understand and evaluate edema in the context of the patient you are assessing. The presence of edema alone does not immediately point to malnutrition, as there are many other clinical reasons for edema to be present. If a patient is reporting normal nutrition intake and appetite, no weight change other than that of fluid fluctuations, then they are not likely to be malnourished. A helpful question to ask yourself may be, if this patient’s fluid were removed, would I expect to find muscle / fat loss concerning malnutrition? There are certainly patients with a history of congested heart failure (CHF) and fluid fluctuations who are also malnourished – it’s a matter of taking all the pieces of the assessment together to make the determination of whether or not malnutrition is present.

Mixed categories for criteria:

This is tough! But patients do not perfectly fit into our boxes for criteria, and spanning multiple categories or seeing a mix of moderate/severe losses on the same patient’s physical exam is not uncommon. The answer to how to handle this probably depends on the patient you are assessing. Choose the level of diagnosis with the most criteria and the strongest evidence. This may be a good question to pose to ASPEN / AND leadership.

Bariatric setting

Validation studies continue to be an area of study for the NFPE in general, and I am not aware of any that are particular to these populations.
Most patients will have some complexity where your findings on NFPE need to be taken into context of their past medical history, nutrition history, weight history, etc.
For obese and bariatric patients, it’s essential to complete NFPEs as you may uncover losses that you do not otherwise see. A thorough nutrition history would be necessary for bariatric patients to help identify normal versus non-normal findings. Establishing UBW post-bariatric surgery, considering post-op complications that may affect nutrition intake, and considering post-op weight loss expectations are all important components to consider if a patient is experiencing malnutrition beyond intentional post-op weight changes.
The AND NFPE training specifically goes over complex populations, including bariatric patients and geriatric patients.

Hand-grip strength Question

The two standard deviations below the mean came from the NFPE training I received from AND. You are correct that it is not specifically mentioned in the consensus and instead says “measurably reduced” and refers to what is considered measurably reduced by the brand of hand dynamometer used. I will reach out to the AND NFPE Trainer team to pose this question.

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