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Symposium 4 Food for Thought – Challenging problems in Malnutrition
Malnutrition: a growing concern
Dr John Puntis
Malnutrition in hospital
• definitions of ‘malnutrition’
• where have these come from?
• clinical surveys
• nutritional screening
• summary
Malnutrition in hospital
• “the prevalence of malnutrition in paediatric hospitals ranges from 15%-30% of patients”
Malnutrition in hospital
• “the prevalence of malnutrition in paediatric hospitals ranges from 15%-30% of patients”
• “malnutrition among hospitalised children is often unrecognised and therefore not treated”
Malnutrition in hospital
• “malnutrition is bad for you”
• “the prevalence of malnutrition in paediatric hospitals ranges from 15%-30% of patients”
• “malnutrition among hospitalised children is often unrecognised and therefore not treated”
Malnutrition in hospital
• impaired immune responses
• reduced muscle strength and fatigue
• reduced respiratory muscle strength
• impaired thermoregulation
• impaired wound healing
• impaired psycho-social function
• growth faltering
Malnutrition in hospital
• increased hospital stay
• increased costs
• justification for ‘screening’?
• evidence in the main from adult studies
Malnutrition in hospital
• how do we link nutritional status to outcomes in children?
• how much malnutrition is bad for you?
Malnutrition in hospital
• how do we link nutritional status to outcomes in children?
• how much malnutrition is bad for you?
• if we cant link malnutrition to outcomes, what point ‘screening’?
Malnutrition in hospital
• how do we link nutritional status to outcomes in children?
• how much malnutrition is bad for you?
• if we cant link malnutrition to outcomes, what point ‘screening’?
however:
• a priori argument for preventing or reversing growth faltering
Malnutrition in hospital
• classification of malnutrition?
• do we all agree?
Malnutrition in hospital
• classification of malnutrition?
• do we all agree?
• problems of definition
• different types of malnutrition:
Malnutrition in hospital
Malnutrition
• under nutrition, due to deficiency of nutrients
• over nutrition, due to an excess of nutrients
• micro-nutrients (trace elements and vitamins)
• macronutrients (protein, fat carbohydrate)
• clinical
• subclinical
Malnutrition in hospital
Malnutrition
• under nutrition, due to deficiency of nutrients
• over nutrition, due to an excess of nutrients
• micro-nutrients (trace elements and vitamins)
• macronutrients (protein, fat carbohydrate)
• clinical
• subclinical
• some definitions . . . . .
Malnutrition in hospital
“A continuum that starts with a nutrient intake inadequate to meet physiological requirements, followed by metabolic and functional alterations and in due course by changes in body composition”.
Malnutrition in hospital
“A state of nutrition in which deficiency, excess or imbalance of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome.”
Malnutrition in hospital
• form
• function
• clinical outcome
Malnutrition in hospital
• form
• function
• clinical outcome
• malnutrition is difficult to define
Malnutrition in hospital
Most obvious and earliest signs of malnutrition in children:
• absence of normal weight gain
• weight loss
• visible decrease in fat; loss of muscle
Malnutrition in hospital
Most obvious and earliest signs of malnutrition in children:
• absence of normal weight gain
• weight loss
• visible decrease in fat; loss of muscle
• malnutrition commonly defined in terms of anthropometry (arbitrary cut offs)
Malnutrition in hospital
Gomez, Journal of Tropical Pediatrics, 1956
• Mexico city; underfed children
• Boston growth standards
• 1sto – weight 76-90% average for age
• 2ndo – weight 61-75% average for age
• 3rdo – weight <60% average for age
• higher death rate 3rdo v 2ndo (22.6% v 33.5%)
Malnutrition in hospital
Gomez, Journal of Tropical Pediatrics, 1956
• Mexico city; underfed children
• Boston growth standards
• 1sto – weight 76-90% average for age
• 2ndo – weight 61-75% average for age
• 3rdo – weight <60% average for age
• higher death rate 3rdo v 2ndo (22.6% v 33.5%)
• link between nutritional status and outcome
Malnutrition in hospital
Jelliffe, WHO Monograph 53, 1966
Assessment of the nutritional status of the community (with reference to field surveys in the developing world)
• ideally local reference population data
• age may not be known accurately
• defining nutritional status of a community
Malnutrition in hospital
Waterlow, Lancet 1972
needs to be standard classification of PCM
• defining prevalence in different countries/communities
• purpose: planning prevention
• community: mild, moderate, severe
• severe cases: qualitative classification to distinguish marasmus, kwashiorkor and intermediate
Malnutrition in hospital
8th report of FAO/WHO Expert Cttee Nutrition
• height/length important
• reflects duration of malnutrition
• weight as percentage of expected weight for given height – acute malnutrition
• height as percentage of expected height for age (where age available) – chronic malnutrition
Waterlow, Lancet 1972
Guide to action at a public health/community level
normal, and
mild
malnutrition
Malnutrition in hospital
McLaren and Read, Lancet 1972
• incorrect to assume that all children of same length should have the same weight
• relationship of weight with height varies with age
McLaren and Read WWC. Lancet 1972
Nomogram for categorising PCM
3 x as much moderate malnutrition!
Minor changes in arbitrary ‘cut offs’ = large differences
WHO Classification
____________________________________________________________
classification
_________________________________
moderate severe
____________________________________________________________
symmetrical oedema no yes
weight for height -3SD - -2SD SD <-3 (<70%)
(70 - 79%) (severe
wasting)
height for age -3SD - -2SD SD <-3 (<85%)
(85 - 89%) (severe
stunting)
____________________________________________________________
Seal A. Institute of Child Health, London, 2008
Impact of using WHO growth standards
Malnutrition in hospital
Merritt RJ. Am J Clin Nutr 1979
• Children’s Hospital Medical Centre, Boston
• all patients > 3 mo
• Waterlow criteria
acute malnutrition (wt for ht <90%) 36%
chronic malnutrition (ht for age <95%) 47%
Malnutrition in hospital
Moy RJD. J Hum Nutr Dietet 1990
• Children’s hospital, >3/12; NCHS; WHO
acute malnutrition (wt for ht <-2SD) 14%
chronic malnutrition (ht for age <-2SD) 16%
scores -1 - -2 SD = “at risk” from
decreased intake, increased requirements,
or losses 20%
• N.B. severe malnutrition mainly chronic disease
Malnutrition in hospital
Hendrickse WH. Clin Nutr 1997
• Children’s hospital;
acute malnutrition (wt for ht <5%) 16%
(<-2SD 11%)
chronic malnutrition (ht for age <5%) 15%
(<-2SD 8%)
“at risk”(-1 -2 SD, ht +/- wt for age) 16%
Malnutrition in hospital
Sermet-Gaudelus. Am J Clin Nutr 2000
• Children’s hospital; >1m
• % ideal body weight; French standards
• underweight 85-90%; mild undernutrition 80-84%; moderate 75-79%; severe <75%
Malnutrition (PIBW <85%) 26%
Waterlow: 80-90%; 70-80%; <70%
Malnutrition in hospital
Pawellek I. Clin Nutr 2007
• Children’s Hospital; German standards; all admissions; Waterlow
mild malnutrition (wt for ht 81-90%) 17.9%
moderate malnutrition (70-80%) 4.4%
severe malnutrition (<70%) 1.7%
(24.0%)
• NB: greatest risk in complex patients
Malnutrition in hospital
Joosten KF. Arch Dis Child 2010
• national; paediatric units; >1m; Dutch standards; WHO criteria
acute malnutrition (wt for ht <-2SD) 11%
chronic malnutrition (ht for age <-2SD) 9%
NB: 44% underlying chronic disease
Malnutrition in hospital
What is ‘nutritional screening’?
rapid, simple and general procedure used by nursing, medical or other staff, often at first contact with the patient, to detect those with significant risk of nutritional problems, so that clear guidelines for action can be implemented
Malnutrition in hospital
Hulst JM. Clin Nutr 2010
• Dutch STRONGkids nutrition screening score
• “to prevent malnutrition along with its complications early identification of nutritional depletion is essential”
• at risk of developing malnutrition: 62%
• median hospital stay 2 days for ‘low risk’, 3 days for ‘high risk’
Malnutrition in hospital
What is being at ‘nutritional risk’?
Malnutrition in hospital
What is being at ‘nutritional risk’?
• not the same as actually being malnourished
Malnutrition in hospital
What is being at ‘nutritional risk’?
• not the same as actually being malnourished
• are screening tools good at predicting health outcomes related to nutritional status?
Malnutrition in hospital
What is being at ‘nutritional risk’?
• not the same as actually being malnourished
• are screening tools good at predicting health outcomes related to nutritional status?
• requires thorough testing, because purpose is to change outcomes
Malnutrition in hospital
What is being at ‘nutritional risk’?
• not the same as actually being malnourished
• are screening tools good at predicting health outcomes related to nutritional status?
• requires thorough testing, because purpose is to change outcomes
• how many children with “mild malnutrition” are ‘thin’? how many show catch up after an acute illness?
Malnutrition in hospital
Are there other indicators of ‘body form’ that might predict outcome?
Categories of BMI for identifying chronic protein-
energy malnutrition in adults ___________________________________________________________
BMI Weight Interpretation of status
(kg/m2) category
___________________________________________________________
<18.5 Underweight chronic under-nutrition probable
18.5 - 20 Underweight chronic under-nutrition possible
20 - 25 Desirable weight chronic under- or over-nutrition
unlikely (low risk)
25 - 30 Overweight increased risk of complications
associated with overweight
>30 Obesity risk of obesity related complications
____________________________________________________________
Briend. Brit Med J 1986. Usefulness of nutritional indices and classification
in predicting death of malnourished children. (Dhaka, n = 352)
arm circumference
weight for age
weight for height
height for age
Malnutrition in hospital
What we don’t have
• a shared understanding of what it means to be ‘at risk’
• a universally agreed definition of malnutrition
• a clear link between ‘malnutrition’ and clinical outcomes
• a cogent argument for ‘screening tools’ as opposed to universal nutritional assessment
Malnutrition in hospital
Summary and conclusions
• definitions of malnutrition based on anthropometry will remain arbitrary until they are linked to clinical outcomes
• estimates of hospital malnutrition vary according to definitions used/reference data
• more recent use of WHO criteria give lower rates than in earlier studies
Malnutrition in hospital
Summary and conclusions
• a priori case for avoiding or reversing growth failure
• growth monitoring (linked to action plans) should be routine for all patients
Malnutrition in hospital
Jelliffe, WHO Monograph 53, 1966
Nutritional anthropometry:
“The interpretation of findings is always complex and often controversial even to leading authorities. The normal healthy well-fed human body can vary so much that interpretation of the nutritional significance of variations in physical dimensions is peculiarly difficult”.
Common classification of protein energy
malnutrition (children)
___________________________________________________________
Normal Mild Moderate Severe
___________________________________________________________
Weight for height* 110-90 90-85 85-75 <75
Weight for age 110-90 90-81 80-61 <60
Weight for age✚ >90 90-75 75-61 <60
Height for age⌘ >95 95-87 87-80 <80
Weight for height⌘ >90 90-80 80-70 <70
___________________________________________________________
presence of oedema = kwashiorkor; no oedema = marasmus
* McLean 1975; Jelliffe1966; ✚ Gomez 1955; ⌘ Waterlow 1972
Child Under-Nutrition in
Affluent Societies: what are we
talking about?
Charlotte M Wright
Ada Garcia
School of Medicine,
Glasgow University
How common is undernutrition?
• Prevalence varies from <1% to 12%
• Depends on measure used:
– Wt, Ht/Length, BMI, WFH, Centile falls, conditional SD change
• Threshold
– 2nd, 3rd, 5th
• Growth reference used
– WHO/CDC 1978, CDC, WHO 2006, IOTF, UK 1990, French
What is under-nutrition?
• No gold standard test
• A net deficit of energy (and other nutrients) resulting in
– Loss of /failure to acquire fat stores
• Depending on severity /duration /age, may also cause
– Slow growth
– Low lean mass
– Metabolic derangement, immune suppression, catabolism
Wasting – low BMI /WFH
• Assumed to reflect low fat
• Sound method to identify acute
malnutrition when under-nutrition
prevalence is high
• Little used in UK till recently
• Little known about clinical significance
Failure to thrive/ weight faltering
• More known about clinical significance
• Variability in how defined and understood – Low weight for age over-identifies infants with low
birth weight
– Centile falls over-identify initially large infants
– Conditional weight gain used for research purposes
• Primary care definition – Fall through 2 centile spaces
– (3 if >91st, 1if <9th)
– But prevalence varies with growth reference used
Natural history of weight faltering
(slowest gaining 5% N=215)
-3
-2.5
-2
-1.5
-1
-0.5
0
0 6 12 18 24 30 36 42 48
Age in months
Mean (
SE
) W
eig
ht
SD
S Whole
cohort
P=0.019
Home visit
P=0.044
Intervention
Intervention
Controls
What causes weight
faltering? • Associated with relative undernutrition
– 2/3 show some evidence of low intake
– Low appetite, feeding behaviour differences
• No clear relationship (in UK) with deprivation
• 5% have other evidence of abuse or neglect – Look for recovery with change of care
• 5-10% cases have symptoms or signs of underlying disease – But if they look well they are well
• How many of the remaining 85% are truly undernourished?
So how common is true
undernutrition in childhood?
• Concordance of weight faltering, wasting
and stunting with fat levels in two
population based cohorts
• Gateshead Millennium Study
– ≈ 860 subjects with anthropometry
aged 1 year
– ≈ 600 with body composition measures
aged 8 years
• ALSPAC
– ≈7,000 children with body
composition measures aged 7-11
ILLENNIUM BABY STUDY
Wasting <2nd centile for BMI
(UK 1990)
Sustained weight
faltering <5th internal centile for
conditional weight gain since
birth at 2 or more ages
Concurrence of different definitions in
GMS cohort
Stunting <2nd centile for length
(UK 1990)
0.6% (5)
4.1% (35) 3.8% (32) 1.8%
(15)
0.4% (3)
0.1% (1) True
undernutrition?
Prevalence = 2.3%
How different measures of undernutrition in infancy relate to
growth and body composition outcomes aged 8 years
-2.00
-1.33
-0.66
Weight BMI Adiposity Lean (BIA) Height Mid parental
height
Z s
co
re
BMI<2nd only (35) Weight faltering only (32) WF plus low BMI or stunting (19)
Wasted =
low average fat
and lean mass
Weight faltering =
low average height but
proportionate to parents
How different measures of undernutrition in infancy relate to
growth and body composition outcomes aged 8 years
-2.00
-1.33
-0.66
Weight BMI Adiposity Lean (BIA) Height Mid parental
height
Z s
co
re
BMI<2nd only (35) Weight faltering only (32) WF plus low BMI or stunting (19)
Short and shorter
than parents
Weight faltering+ = low fat and lean mass
ALSPAC study
Ages 7-11 years
19% <2nd
have low fat
46% above 95th
have high fat
79% of those
<BMI 2nd,
were >fat 5th
centile
52% of those
<BMI 2nd,
were <lean
5th centile
Does a low BMI in
childhood?
actually reflect low
reserves
79% of those with
BMI below 2ndcentile
were above fat 5th
centile
52% of those
with BMI
below 2nd
were below
lean 5th
centile
Concurrence of low BMI and fall in BMI with
low body fat in ALSPAC, aged eleven
Wasting <2nd centile for BMI
(UK 1990) Low fat <5th internal centile for
fat (BIA) adjusted for
height, age, gender
BMI SD change <5th internal centile
4.0% (237)
1.0% (62)
4.9% (291)
0.12%
(7)
0.74% (44)
0.18%
(11)
0.08% (5)
True undernutrition?
Prevalence = 1.12%
Concurrence of low BMI and fall in BMI with
low body fat in ALSPAC, aged eleven
Wasting <2nd centile for BMI
(UK 1990) Low fat <5th internal centile for
fat (BIA) adjusted for
height, age, gender
BMI SD change <5th internal centile
4.0% (237)
1.0% (62)
4.9% (291)
0.12%
(7)
0.74% (44)
0.18%
(11)
0.08% (5)
True undernutrition?
Prevalence = 0.38%
How should under-nutrition be
diagnosed?
Sceptically, without relying on a single
measure
Weight trajectory
BMI
Skinfolds (DXA / BIA)
Response to treatment
Functional assessment
Undernutrition in childhood in
the UK
• Still present in ≈ 2% infants, <1% children
• Many screen positive cases are not
undernourished at all
• Most of rest are only mildly undernourished
– Assess sensitively
– Treat proportionately
• A few will have organic disease or be suffering
neglect
– Look for supporting evidence
– Not a diagnosis by exclusion
My thanks to:
• All involved with Gateshead Millennium and ALSPAC studies
Funders
• Henry Smith Charity
• SPort Aiding Research in KidS
• Newcastle, North Tyneside and Northumberland NHS R&D
• Scottish Chief Scientists Office
• NPRI
• British Heart Foundation
WHO 2006 standard describes how all children <5 years should grow
Impact of new WHO standard
• Reduces prevalence of low weight, BMI or WFH
compared to earlier standards
– But increases prevalence of wasting <6m
• WHO estimates of prevalence in affluent
countries
– Low weight for age (-2SD) 1.6%
– Stunting (height for age <-2SD) 6%
• BMI /WFH from single studies (UK, USA)
– 4m 2 %
– 8m onwards <1%
Concurrence of wasting and stunting
with low body fat in ALSPAC aged Seven
Wasting <2nd centile for BMI
(UK 1990)
Low fat <5th internal centile for
fat (BIA) adjusted for
height, age, gender
Stunting <2nd centile for length
(UK 1990)
1% (81)
0.9% (68)
4.7% (364)
0.26%
20
0.07% (6)
0.03% (2)
Concurrence of low BMI, fall in BMI and
stunting with low body fat in ALSPAC aged
eleven
Wasting <2nd centile for BMI
(UK 1990)
Low fat <5th internal centile for
fat (BIA) adjusted for
height, age, gender
Stunting <2nd centile for length
(UK 1990)
0.62% (45)
1.5% (108)
4.6% (335)
0.37%
(27)
0.1% (7)
0.03% (2)
0.01% (1)
Roswyn Hakesley-Brown
CBE MPhil, BA, RN Chair, The Patients Association
The Prevalence of
Malnutrition in
General Practice
Paula McGurk PhD RD
Research Dietitian
University Hospital Southampton NHS
Foundation Trust
Professor Marinos Elia
Dr Abbie Cawood
Dr Rebecca Stratton
Distribution of Malnutrition in the UK
according to Care Setting
~2% hospital
~5% care homes
~93% community (2-3% sheltered
accommodation)
(Elia & Russell, 2009)
Prevalence of Malnutrition in General
Practice (GP)
Few reports (Edington et al 1996; Martyn et al 1998; Turnbull & Sinclair 2002)
Often reported in specific patient groups and
populations, e.g. malnutrition in cancer patients
Inconsistency in patient selection procedures and
methods of identifying malnutrition
No reports of large series involving patients
consecutively visiting their GP, screened using
consistent criteria, such as those in ‘MUST’
Aims
1. a) What is the prevalence of malnutrition in
people visiting their GP and to what extent is it
identified and treated?
b) How representative is the study population of
the general population in England?
2. Is malnutrition related to health outcomes and
healthcare use?
k
Methods
Developed a questionnaire
Attended a Practice Manager forum
6 General Practices agreed to host
Visited surgeries (Nov ‘10- May ’11)
General characteristics
Age, gender, GP
Postcode
*Health Outcomes
Unhealed wounds,
Infections, Weight loss
*Healthcare use
GP visits
Antibiotic use
*In the previous 6 months
Methods
Weight, Height and Weight loss (used data to
apply ‘MUST’ criteria)
Rank of Index of Multiple Deprivation Score
established using GP postcode
(1 (most deprived) - 32,482 (least deprived) )
(Nobel et al 2011)
Health outcomes & healthcare use: Questionnaire
Results 1a: Patients
146 were
relatives/carers/
friends
970 invited to
participate
601 (62%)
screened
455 were
attending for an
appointment
Variable Mean SD
BMI
(kg/m2) 26.3 ± 5.3
Weight
(kg) 73.9 ±17.1
Age (yrs) 41.8 ±18.3
369 (38%) did
not participate
6.2%
4.6%
0
2
4
6
8
10
12
%
High risk
Medium risk
Results 1a: Medium and High risk patients
(n 455)
‘MUST’ category
10.8%
Results 1a: Prevalence of Malnutrition
(M+H risk)
(n 455)
Step 1; BMI contribution
to MUST: 39 / 455 (8.7%)
Step 2; Weight loss
contribution to MUST:
14 /455 (3%)
Step 3 Acute disease
score effect; No
contribution
7.8% 2.1%
Wt loss
3%
Overall prevalence 10.8% (95% CI 8.2% 14.0%)
0.9%
8.7%
BMI
LEAST
DEPRIVED
MOST
DEPRIVED
1
32,482
Average in England (16,241)
General Practice (4474 – 14811;
mean 8138)
1.b: Rank of Index of Multiple Deprivation Score
Results 2: Health Outcomes and
Healthcare use (last 6 months)
2.2%
16.7%
60.6%
8.2%
24.5%
65.3%
0
20
40
60
80
Unhealed wounds
Infections requiring Abx
≥1 GP visit in last 6 months
% o
f p
op
ula
tio
n
Low risk
Med & High riskSignificantdifference(P<0.05)
P=0.23
P=0.64
Discussion and conclusion
1. a) Prevalence of malnutrition in those attending
the GP is 10.8% (95% CI 8.2%, 14.0%), all of
which was unrecognised and untreated.
b) All practices were located in areas of higher
deprivation (caution in generalisations)
2. Current malnutrition tended to be associated with
adverse health outcomes and increased
healthcare use during previous 6 months.
References
Elia M (Editor) 2003 The ‘MUST’ report. BAPEN, Redditch.
Elia M & Russell C.A (2009) Combating Malnutrition:
Recommendations for Action.
Nobel et al (2011) Indices of Deprivation 2010 for Super
Output Areas (www.communities.gov.uk)