Correlation of New Criteria for Malnutrition Assessment in Hospitalized Patients: AND-ASPEN Versus SGA.

Objectives: Identifying malnutrition in the hospitalized patient is important as it correlates with increased morbidity. The Subjective Global Assessment (SGA) is recognized in the literature as a standardized and validated method for diagnosing malnutrition. The Academy of Nutrition and Dietetics (AND) and the American Society for Parenteral and Enteral Nutrition (ASPEN) developed a comprehensive method (AND-ASPEN criteria) for diagnosing malnutrition that has yet to be validated. In effort to validate the AND-ASPEN criteria for identifying malnutrition, this study investigated whether AND-ASPEN criteria would correlate with SGA in hospitalized patients.Methods: A cohort of patients >18 years old admitted to a tertiary hospital and assessed for malnutrition using AND-ASPEN criteria were randomly selected, and a retrospective review was completed. Criteria needed to perform SGA were extracted from the electronic medical record and SGA data were calculated and compared to AND-ASPEN malnutrition scoring. Spearman's correlation coefficient was used to assess correlation between the SGA and AND-ASPEN malnutrition score. Data are presented as mean ± standard deviation, median or frequency.Results: A total of 409 patients were reviewed and 225 (55%) met inclusion criteria. SGA malnutrition scores classified 47.1% (n = 106) of subjects as well-nourished, 32% (n = 72) moderately malnourished, and 20.9% (n = 47) severely malnourished. The AND-ASPEN malnutrition scores classified 43.8% (n = 179) of the subjects as well-nourished, 26.2% (n = 107) as moderately malnourished, and 30.1% (n = 123) severely malnourished. The SGA score and AND-ASPEN malnutrition diagnosis were found to be correlated (p < 0.001). There was no association between age or length of stay with either assessment tool.Conclusions: The AND-ASPEN criteria for diagnosing malnutrition correlated with SGA in identifying nutritional status in hospitalized adult patients. Future prospective studies capturing the impact of malnutrition diagnosis, medical and nutrition interventions with patient outcomes are warranted to confirm the impact of early and accurate identification of malnutrition of patient outcomes.

Comparison Between Handgrip Dynamometry and Manual Muscle Testing Performed by Registered Dietitians in Measuring Muscle Strength and Function of Hospitalized Patients.

BACKGROUND: The Academy of Nutrition and Dietetics and American Society the Parenteral and Enteral Nutrition (ASPEN) Consensus Statement recommends a standardized set of diagnostic characteristics to identify adult malnutrition. Due to lack of a consensus definition and challenges with measurements, physical function or performance has traditionally been difficult to assess. The purpose of this study was to determine whether manual muscle testing (MMT) performed by registered dietitians (RDs) can be used as a surrogate measurement of muscle strength and function in hospitalized patients. METHOD: Patients admitted to the heart failure service on the cardiac stepdown units at the Cleveland Clinic Main Campus in Cleveland, Ohio, were eligible for the study, and those who met the inclusion criteria underwent handgrip strength (HGS) testing and evaluation of nutrition status using the Academy/ASPEN Characteristics Recommended for the Identification of Adult Malnutrition. MMT was then performed within 24 hours by a different study investigator blinded to the HGS and malnutrition assessment results. RESULTS: It was found that HGS and MMT overall were in agreement for 84% of patients and that MMT had a high sensitivity (98%) but low specificity (13%). CONCLUSION: This study shows feasibility for RDs to perform MMT on patients to determine muscle strength and functioning. Future practice application may be to incorporate MMT into screening criteria for patients being evaluated for malnutrition and reserve HGS testing only for patients with an abnormal MMT.

Evaluation of muscle and fat loss as diagnostic criteria for malnutrition.

According to the American Society for Parenteral and Enteral Nutrition and Academy of Nutrition and Dietetics criteria, the diagnosis of malnutrition includes an evaluation of muscle and fat. The role of inflammation not only enhances the catabolism of muscle and fat loss but also interferes with anabolism. Dietitians and other nutrition professionals need to understand techniques to appropriately identify losses of muscle and fat to incorporate them into a malnutrition diagnosis. Proper training is imperative to correctly identify muscle and fat wasting in a consistent and reliable manner. Nutrition clinicians should begin incorporating these practices into patient assessments and care plans. The application of these techniques and assessment tools is challenging and continues to be a work in progress. Various scenarios do not allow for clearly defined methods that would lead to a reliable conclusion for diagnosing malnutrition indicating the need for further research.

Sarcopenia and a physiologically low respiratory quotient in patients with cirrhosis: a prospective controlled study.

Patients with cirrhosis have increased gluconeogenesis and fatty acid oxidation that may contribute to a low respiratory quotient (RQ), and this may be linked to sarcopenia and metabolic decompensation when these patients are hospitalized. Therefore, we conducted a prospective study to measure RQ and its impact on skeletal muscle mass, survival, and related complications in hospitalized cirrhotic patients. Fasting RQ and resting energy expenditure (REE) were determined by indirect calorimetry in cirrhotic patients (n = 25), and age, sex, and weight-matched healthy controls (n = 25). Abdominal muscle area was quantified by computed tomography scanning. In cirrhotic patients we also examined the impact of RQ on mortality, repeat hospitalizations, and liver transplantation. Mean RQ in patients with cirrhosis (0.63 ± 0.05) was significantly lower (P < 0.0001) than healthy matched controls (0.84 ± 0.06). Psoas muscle area in cirrhosis (24.0 ± 6.6 cm(2)) was significantly (P < 0.001) lower than in controls (35.9 ± 9.5 cm(2)). RQ correlated with the reduction in psoas muscle area (r(2) = 0.41; P = 0.01). However, in patients with cirrhosis a reduced RQ did not predict short-term survival or risk of developing complications. When REE was normalized to psoas area, energy expenditure was significantly higher (P < 0.001) in patients with cirrhosis (66.7 ± 17.8 kcal/cm(2)) compared with controls (47.7 ± 7.9 kcal/cm(2)). We conclude that hospitalized patients with cirrhosis have RQs well below the traditional lowest physiological value of 0.69, and this metabolic state is accompanied by reduced skeletal muscle area. Although low RQ does not predict short-term mortality in these patients, it may reflect a decompensated metabolic state that requires careful nutritional management with appropriate consideration for preservation of skeletal muscle mass.

Handheld calorimeter is a valid instrument to quantify resting energy expenditure in hospitalized cirrhotic patients: a prospective study.

BACKGROUND: Nutrition management of cirrhosis in hospitalized patients is overlooked despite the clinical significance of sarcopenia or loss of muscle mass in cirrhosis. Determining optimal nutrition requirement needs precise measurement of resting energy expenditure (REE) in the cirrhotic patient. Predictive equations are not accurate, and the metabolic cart is expensive and cumbersome. The authors therefore performed a prospective study to examine the feasibility and accuracy of a handheld respiratory calorimeter (HHRC) in quantifying the REE in hospitalized cirrhotic patients not in the intensive care unit. MATERIALS AND METHODS: The study was done in 2 phases: in the first phase, the REE of 24 consecutive healthy volunteers was measured using an HHRC in different positions. The objective of this phase was to identify the impact of body and arm position on measured REE. Subsequently, in the second phase of the study, REE was measured using the HHRC and the metabolic cart in 25 consecutive well-characterized, hospitalized cirrhotic patients. The degree of concordance was calculated. RESULTS: Body position and arm position did not significantly affect the measured REE using HHRC. In patients with cirrhosis, the mean measured REE (kcal/d) using the HHRC was 1453.2 ± 319.3 in the hospital room, 1525.6 ± 305.2 in a quiet environment, and 1553.7 ± 270.6 with the metabolic cart (P > .1). Predicted REE using 2 widely used equations did not correlate either with each other or with the measured REE. CONCLUSIONS: HHRC is a valid, feasible, and rapid method to determine optimal caloric needs in hospitalized cirrhotic patients.

Do handheld calorimeters have a role in assessment of nutrition needs in hospitalized patients? A systematic review of literature.

BACKGROUND: Indirect calorimetry is a noninvasive and reliable means of determining resting metabolic rate in humans. Barriers to obtaining an accurate measure of resting metabolic rate (RMR) in hospitalized patients include the expense and the requirement of technical expertise for maintenance. METHODS: A literature search on handheld calorimeters was conducted using PubMed and OVID. The search resulted in a total of 54 published articles; 23 of these specifically are about handheld calorimeter devices. RESULTS: Results from a handheld calorimeter were similar to those obtained from metabolic cart studies. The Douglas bag method compared with the MedGem indicated a significant agreement (P = .286). The handheld device was compared with metabolic carts in 9 studies with mixed results. The predictive equations (Harris-Benedict, Mifflin-St Jeor, and FAO/WHO equations) over- and underestimated RMR compared with the MedGem. The Harris-Benedict equation overestimated the RMR by 3%-11%, the Mifflin-St Jeor equation overestimated the RMR by 1%, and the FAO/WHO equation overestimated RMR by 12%. CONCLUSION: The present study examines the validity and reliability of handheld calorimeters for measuring resting energy expenditure based on published literature. Handheld calorimeters are more accurate than predictive equations based on gender, age, and ethnicity for determining resting metabolic rate and are therefore a viable alternative for clinical evaluation of the hospitalized patient.