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DR. CHARLOTTE PRATT: Hello, my name is Charlotte Pratt,
and I'm a Deputy Chief and Program Director at the  

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National Heart, Lung, and Blood Institute here 
at the National Institutes of Health. I co-chair  

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the Medical and Nutrition Implementation 
Working Group with Dr. Christopher Lynch,  

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and I am a member of the organizing committee 
for this workshop. Welcome. We are delighted  

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you are attending the Malnutrition in Clinical 
Settings, Research Gaps and Opportunities Workshop.  

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As Dr. Lynch mentioned in the welcome video, this 
workshop is hosted by the National Institutes  

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of Health Office of Nutrition Research and 
is relevant to one of the goals of the NIH  

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Strategic Plan for Nutrition Research. That 
is the goal to reduce the burden of diseases  

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in clinical settings. The overarching 
objective of the workshop is to identify  

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research gaps and opportunities to fulfill 
that goal. You have probably heard the quote,  

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"Let food be thy medicine," from Hippocrates, who is 
the father of medicine. This workshop has several  

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objectives to address the concept of food as 
medicine to curtail many chronic diseases. 

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These objectives include summarizing the state 
of the science and identifying knowledge gaps and  

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opportunities related to malnutrition in clinical 
settings; discussing research to understand,  

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measure, and address malnutrition in clinical 
settings; and identify ways to train and  

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increase the diversity of the clinical nutrition 
workforce to help close the health equity gap.  

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These objectives are very important 
because in a recent systematic review  

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by the Agency for Healthcare Research and Quality 
malnutrition among hospitalized patients remains  

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a serious issue, affecting more than 30% of 
hospitalized patients in the United States.  

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Malnutrition leads to high morbidity 
and mortality, functional decline,  

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prolonged hospital stays, and increased health 
care costs. Early identification and treatment  

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of malnutrition are critical to preventing 
poor health outcomes in hospitalized patients.  

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Proper screening and tools for accurate diagnosis 
and assessment are essential to identifying and  

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utilizing appropriate interventions.
By addressing the workshop objectives,  

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including challenges faced with training the 
next generation of diverse nutrition workforce,  

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we hope to bring you much food for thought. 
Again, welcome, and thank you for attending this  

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workshop. I would like to introduce Dr. Griffin 
Rogers, Director for the National Institute of  

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Diabetes and Digestive and Kidney Diseases, who 
will also welcome you. Again, thank you very much.

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DR. GRIFFIN ROGERS: Good morning. I'm Dr. Griffin 
Rogers, Director of the National Institute  

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of Diabetes and Digestive and Kidney Diseases, or 
NIDDK. I'm pleased to join with colleagues from  

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the Office of Nutrition Research and others 
at NIH, professional societies, and academic  

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partners in welcoming you to the kickoff of this 
NIH workshop on malnutrition in clinical settings.  

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As the institute funding the largest 
amount of nutrition research at NIH,  

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the NIDDK has a long-standing commitment 
to supporting researches that advances  

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understanding and clinical care of many chronic 
disease-related diseases within our mission.  

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This encompasses work on both overnutrition 
and undernutrition in terms of caloric and  

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micronutrient intake. We support research 
on the way the body absorbs and responds to  

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nutrients and how factors—such as disease, stress, drugs, toxins, the gut microbiome, and treatment, 

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such as bariatric surgery—affects the absorption and metabolism of nutrients. Malnutrition in  

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both adults and children, whether due to diet or 
disease, is one of NIDDK's research priorities. 

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The institute supports ongoing work by 
investigators across the country and abroad  

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to identify the factors at play at malnutrition 
and to develop innovative solutions. For example,  

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we've partnered with the Bill and Melinda Gates 
Foundation to support long-standing studies of  

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childhood malnutrition in Bangladesh and Malawi. 
These studies have identified the key role of the  

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gut microbiome and develop dietary supplements 
that boost microbial species needed for healthy  

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growth and development. Related to today's focus 
on adult malnutrition in the clinical setting, the  

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NIDDK funds research on malabsorption resulting 
from digestive diseases such as inflammatory bowel  

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disease, chronic pancreatitis and other forms 
of pancreatic disease, chronic liver disease,  

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chronic kidney disease, cystic fibrosis, and 
from weight loss procedures to treat obesity.  

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These studies are part of investigator-initiated 
projects, as well as larger efforts, such  

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as the Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer;

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Gastroparesis Clinical Research Consortium; the 
Longitudinal Assessment of Bariatric Surgery;  

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cystic fibrosis research and translation centers;  

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HiLo study of people with kidney failure 
on dialysis; and a new Liver Cirrhosis Network. 

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Many of these efforts are done in partnership 
with other NIH institutes, patient organizations,  

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and private industry. The NIDDK also funds the 
Nutrition Obesity Research Centers Program,  

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a national research resource program that fosters 
interdisciplinary basic, clinical, translational,  

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and public health research related to nutrition 
and obesity. One of the NIDDK's guiding principles  

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is to foster a strong and inclusive scientific 
workforce through our many programs supporting  

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training and career development at each step of 
the career pathway. And you'll hear more later  

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in this workshop about the trans-NIH
commitment to supporting training of a robust,  

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diverse, and inclusive research workforce. On our 
website, niddk.nih.gov, you can find information  

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about our research training programs as well 
as contact information or NIDDK program staff,  

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some of whom are participating in this workshop. 
They're always pleased to hear from members of  

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the scientific community with new ideas to share.
And I encourage all researchers, especially those  

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just starting out, to contact them. Well, in 
addition to our research and training program,  

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the NIDDK provides health information in 
response to questions about nutrition and  

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weight management from health professionals and 
the public through its Health Information Center.  

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NIDDK is honored to be a part of this workshop, 
welcoming so many participants from the community  

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to join us in considering research-based solutions 
to address malnutrition. I look forward to hearing  

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the presentations and discussions to advance 
work on this very important topic. Thank you.

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DR. GAIL CRESCI: Hello. My name is Gail Cresci, and I'm an associate 
professor in the Cleveland Clinic Lerner College  

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of Medicine of Case Western Reserve University 
and full staff in the departments of Pediatric  

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Gastroenterology and Inflammation and Immunity 
at the Cleveland Clinic in Cleveland, Ohio.  

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I am also the immediate past president 
of the American Society for Parenteral  

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and Enteral Nutrition. I am one of the medical 
nutrition implementation working group members.  

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Our working group members are leaders 
and represent the main clinical nutrition  

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societies in the United States—The American 
Society for Parenteral and Enteral Nutrition,  

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the Academy of Nutrition and Dietetics, 
and the American Society of Nutrition.  

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Along with the other working group members—Dr. Todd 
Rice of Vanderbilt University Medical Center; 

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Dr. David Sears, Columbia University Medical Center; 
Dr. Allison Steiber, Academy of Nutrition and  

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Dietetics and Dr. Nilesh Mehta, Boston Children's 
Hospital and Harvard Medical School—we are  

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honored and excited to have had the opportunity 
to plan this comprehensive workshop that addresses  

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the current status of clinical malnutrition from 
definition, its economic burden, its diagnosis,  

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biomarkers, and future potential interventions 
to future research opportunities and directions  

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to address the identified clinical gaps 
that we'll find throughout this workshop. 

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I now would like to introduce your moderator 
for Session One, Dr. Kelly Tappenden.  

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Dr. Kelly Tappenden received her Ph.D. in 
Nutrition and Metabolism at the University  

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of Alberta. And following postdoctoral training at 
The University of Texas Medical School in Houston,  

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she joined the faculty at the University 
of Illinois in Urbana and was there for  

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more than 15 years where she rose through 
the ranks from assistant to full professor.  

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Dr. Tappenden's current position is professor 
and head at the Department of Kinesiology  

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and Nutrition at the University of Illinois at 
Chicago. Dr. Tappenden's research program focuses  

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on intestinal failure, mechanisms regulating 
epithelial function, and patient malnutrition.  

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For these contributions, she 
has received multiple awards,  

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published over 100 peer-reviewed papers, 
and delivered over 500 invited lectures.  

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Dr. Tappenden served as the 33rd president for the 
American Society for Parenteral and Enteral Nutrition  

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in 2008/2009. She also was chair of Nutrition, 
Metabolism, and Obesity section of the American  

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Gastroenterology Association Institute from 
2009 to 2013, and she was editor-in-chief of  

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the Journal for Parental and Enteral Nutrition, the 
scientific journal for ASPEN, from 2010 to 2022. 

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Dr. Tappenden currently represents the American 
Society for Nutrition on the Federation of  

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American Societies for Experimental Biology 
Board of Directors. Welcome, Dr. Tappenden.

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DR. KELLY TAPPENDEN: Thank you, and welcome to our 
introductory session and Session One. We have  

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a very strong list of presenters set up for you 
today. First, for the introduction, Drs. Roman and  

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Jensen will provide an overview of malnutrition— 
both outside the hospital, highlighting community  

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issues, and then in the medical setting. We'll 
then move on to session one. The speakers will  

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provide an overview of the cost of malnutrition in 
the clinical setting. We will begin with the scope  

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of the problem and the cost of not addressing 
this important problem. So first Dr. Winkler, will  

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provide an overview of the AHRQ report. Then, Dr. 
Guenter will discuss the Value Project, Ms. Mitchell  

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will present on accelerating malnutrition 
quality of care through quality measurement  

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and finally, Dr. Kerr will follow and discuss the 
economics of nutrition and health care. So during  

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these sessions, please share your questions for 
the presenters in the chat box. What we're going  

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to do is try and address as many as we can in the 
question-and-answer session that follows live with  

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the presenters afterwards.
So, here we go.

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NANCY ROMAN: Morgan DiCesar was finishing up her 
freshman year at the University of  

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Minnesota in Spring 2010 when her 
vision started giving her trouble.  

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She thought late-night studying was causing 
it. But she went to the doctor who couldn't  

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find anything wrong with Morgan's eyes, but 
suggested she get a brain scan just to be safe.  

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The scan discovered a rare brain tumor that was 
growing rapidly, already impacting the nerves that  

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control eye movement. Her face was going numb. 
Her tumor was so advanced it could no longer be  

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treated with radiation. Yet new technology allowed 
her doctor to use microsurgical techniques to  

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remove it completely. She was in the hospital just 
5 days. Her symptoms were gone in 1 week.  

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Les Baugh lost both of his arms at the shoulder 
during a horrible electrical accident when he  

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was a teenager. Two years ago, he got robotic 
arms that move according to his thoughts,  

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like any other. This arm has 26 joints, can 
curl up to 45 pounds. Wow. Advances in technology and  

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medicine are allowing us to cure disease 
and repair disability as never before. 

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As a nation and world, we've gotten very good 
at improving poor health or damaged bodies,  

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but we just aren't nearly as good at preventing 
health from going bad in the first place.  

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Accordingly, 100 million of us live with diabetes 
and pre-diabetes. More than 600,000 people—could  

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be us, could be our family members—will die of 
heart disease this year, and we're more likely to  

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get myeloma, colorectal, uterine, gallbladder, 
kidney, and pancreatic cancers than before.  

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Americans prize freedom so much, yet we're trapped 
in a food culture that's making us sick. Why,  

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when food can also make us well? My dear friend 
Nancy Mitchell burned her wrist badly, taking a  

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roasted chicken out of the oven. The roasting pan 
fell on her arm and seared the skin to the bone.  

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She went to Duke Burn Center, one of the top 
burn centers in the world. Now, she's a swimmer,  

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so her primary concern was how quickly 
would she be able to get back in the pool.  

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Her doctor treated the burn and then 
told her that from this point forward,  

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the single most important determinant in the 
speed of her healing would be what she ate— 

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lots of vegetables, only lean meat, plenty 
of protein. Her food would determine the  

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pace of her healing. We now know that food and 
nutrition determine a child's brain development.  

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Food determines the likelihood of getting 
diabetes, heart disease, and cancer. We have this  

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incredible burden of knowledge, and yet it's so 
very hard to respond to this burden of knowledge.

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Why is that? Well, we're up against a lot when we 
try to eat smart. For one thing, we're up against  

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our very own taste buds. It turns out we're 
hardwired to crave salt, fat, and sugar. And if  

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you were a hunter-gatherer who stumbled on a honey 
tree, it would have served you to eat up all that  

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honey. And if you scored a kill, you would have 
lived longer had you eaten all the fat along with  

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the lean. Calories were scarce, and people were on 
the move. Sweetness came from fruit. Now it comes  

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from triple-stuffed Oreos, caramel lattes, added 
sugars, and everything. Not only do our taste buds  

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love salt, fat, and sugar, but when you compound 
our genetic predisposition with the power of food  

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marketing, and culture, it becomes near impossible 
to make better choices and to avoid bad ones. 

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So what do I mean? Let's take a look at the 
evolution of snacking foods from the turn of the  

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century through the agricultural revolution to the 
industrial area. In 1893, Cracker Jacks arrived,  

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and in 1900, the Hershey Bar. In 1912 came 
the Oreo, and Hostess cupcakes in 1919.  

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But up through this period, American life included 
so much more physical activity, and these foods  

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were infrequently consumed. They were treats in 
the truest sense of the word. The processed snack  

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food industry didn't shift into high gear until 
right after World War I when the stock market  

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boom gave rise to new snack foods and the leisure 
time to enjoy them. And so you see the quickening  

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pace of innovation with sugar, sodium, and fat 
that produces lots of delicious, not so great for  

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us food. The 20s gave us Eskimo pies, Girl Scout 
cookies, gummy bears, and my fave, Velveeta cheese.  

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The 30s, despite the Great Depression, brought 
Twinkies and Fritos, the 40s, Dairy Queen, M&Ms,  

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and Cheetos. But put on your seat belts, folks.
Here come the 1950s; Dunkin Donuts, Oreida French  

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fries, Cheeze Whiz, and Pepperidge Farm cookies, 
Eggo waffles, TV dinners, KFC, refrigerated cookie  

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dough, ruffles. And this crescendo of junk food 
was our very own fault. America's food companies  

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gave consumers exactly what we asked for: 
quick, convenient, tasty food at good prices.  

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But in so doing, without attention to how 
salt, fat, and sugar are tied to our health,  

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these very foods helped create our broken food 
culture. The broken food culture, of course,  

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leads to our sick patients, neighbors, families, 
and friends. The national adult obesity rate is  

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up 26% just since 2008. So now more than 40% 
of adults and 20% of children between the age  

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of 2 and 19 in the United States live with 
this condition and associated diseases. And  

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if you're low income, it's more likely to be you 
because there's such a strong link between food  

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insecurity and all ten of the chronic diseases 
measured by the CDC-hypertension, coronary heart  

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disease, hepatitis, stroke, cancer, asthma, 
diabetes, arthritis, COPD, and kidney disease. 

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Now some of you have or will encounter 
these patients in the clinical setting.  

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Others are doing research meant to inform the 
clinical setting. I come to this discussion after  

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two decades in the hunger and malnutrition sphere. 
First, at the United Nations World Food Program,  

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the world's largest humanitarian agency providing 
food to 100 million people in 75 countries,  

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mostly in emergency settings. There, we were...
most often encountered malnutrition in the  

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form of undernutrition, and it wasn't easy 
to look at. On a trip to Ethiopia in 2008  

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when I joined a team assessing impact 
of drought on health and nutrition,  

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I saw a man collapse and die from starvation 
as he approached one of our hunger clinics.  

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In Haiti, a woman once begged me to take her 
baby because she could no longer feed him.  

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In those heartbreaking situations, people suffered 
from a life-draining lack of both calories and  

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nutrients that is visible and easy to understand. 
Too little food equals too little nutrition.  

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So it was an adjustment to return to the United 
States and begin to understand the malnutrition  

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here aided and abetted by our culture full 
of junk food where calories are plentiful,  

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but nutrition can be in short supply.
I saw the effects of this kind of  

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malnutrition up close and personal as head of the 
Capital Area Food Bank, serving 500,000 people in  

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greater Washington, DC. There, we worked with and 
for a malnourished population that often showed up  

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as overweight people. Salty, fatty, calorie-laden 
diets lacked the nutrition they needed to build  

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health but had more calories than would allow them 
to maintain a healthy weight. It's critical to  

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understand that while people in the United States 
may not be collapsing from a lack of calories and  

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energy, the onset of and/or aggravation of 
the many chronic diseases mentioned above  

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are diminishing the lives of millions needlessly 
right now, right here in the United States.  

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A whopping 53.6 million people live in low-income, 
low-access communities more than 10 miles from  

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any grocery store. That's one of six of every one 
of our fellow citizens. It's not only harder for  

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them to get good food, but harder for them to 
work their way out of this health-diminishing  

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food trap because of place-based realities 
we call the social determinants of health. 

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How can we fail to use food as a tool for health 
when our broken food culture is either the driver  

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of or the result of all five determinants 
of health? Let's consider them. Number one; Economic Stability.

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Economic instability clearly 
drives food insecurity. We know those who struggle  

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to make ends meet, cut meals and default to 
the cheapest fast foods and processed carbs.  

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Two, education. Lack of good food 
certainly undermines education. We  

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know that when you're hungry, it's hard to pay 
attention in school to learn or even to think.  

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Number three; Health and Health Care. The health 
system has so far failed to acknowledge poor food  

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as a prime driver of poor health or, more 
frustratingly, to leverage good food as a  

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tool to improve health. It has failed to require 
sufficient hours of nutrition education as part  

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of med student curricula, leaving intelligent 
doctors much less informed and knowledgeable  

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than they should be about food as a factor in 
their patients' conditions or food as medicine. 

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Number four; Neighborhood and Built Environment. 
We know built environment and low-income areas  

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feature fast food on every corner and 
precious little access to vegetables  

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and other whole food. You won't find a 
Sweetgreen or a Whole Foods in Ward 8,  

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Washington, DC, or any other under-resourced 
neighborhood. Number five; Social and Community  

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Context. The social events and family culture in 
under-resourced communities are high in salty,  

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fatty diets and fast food that dominates the built 
environment. And if you aren't persuaded yet,  

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let's consider what this broken food culture is 
costing in dollars and cents. Adults struggling  

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with obesity spend 42 percent more on direct health 
care expenses than peers at a healthy weight.  

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75 percent of all U.S. health care spending is spent on 
patients with one or more chronic conditions.  

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We spend $300 billion treating heart disease every 
year and $327 billion treating diabetes, so the  

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food culture we're trapped in is costing $1.3 
billion per year and direct and indirect costs. 

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Yet what surprises me most is our stunning failure 
to respond to this incredible burden of knowledge.  

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Are we really trapped? Why do we accept this?  

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Because we have understood our broken food 
culture as something that cannot change.  

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We see the broken food culture as water to a fish— 
the immutable environment. In fact, our broken  

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food culture is not immutable. It can change. It 
must change, and we must be the ones to change it.  

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Fortunately, I'm not alone in thinking this way, 
and I will close with four signs of hope.  

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One, leadership truly matters and we are beginning 
to see some. Dr. Agnes Kalibata, who led the UN Food  

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System Summit to success last year, which 
spawned global activity around the world,  

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including right here in the United States, where 
the Biden administration is stepping up with the  

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coming White House Conference on Nutrition, 
September 28. The World Economic Forum,  

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as an outcome of that effort, worked with 
80 global food companies to consider why  

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the food system produces so much unhealthy food.
And they've concluded that public health has just  

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been too low on the corporate agenda. So look 
for that to begin to change as leaders step up.  

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Number two; innovation. In my role at PHA, we 
are often approached by entrepreneurs working  

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on new models aimed at getting high-quality food 
to lower-income customers—a real challenge.  

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Both the number of entrepreneurs and the 
quality of their ideas are improving.  

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Number three, the next generation gets it. Young 
food leaders from 37 countries gathered for the  

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Food System Summit last year. They ranked the many 
issues dogging the food system, from lack of soil  

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health to low wages for farmers. Their number 
one issue was healthy food for all. "We want  

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to ensure that everyone everywhere has access 
to healthy, sustainable, and resilient food."  

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And finally, number four; There's some 
really smart non-profit work catalyzing  

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change, and I'll describe ours. At PHA, we're 
building a food equity movement. As part of that,  

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we're equipping pediatricians with information 
about the importance of vegetables in the diets  

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of infants and children and tips on how 
to introduce them...to young parents, 

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so we set up a generation 
with healthy eating habits.  

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We've designed a Good Food for All produce 
program that distributes vegetables and fruits  

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through a saturation model. Families receive 
two servings of produce per day, per person,  

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7 days a week for 12 successive weeks. Our 
data shows that a fruit habit is established by  

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week 7 and a vegetable habit between weeks 10 
and 12. These are powerful findings to build on.  

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And we're piloting the sale of plant-forward meal 
kits that compete with fast food in price and  

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taste. We must offer alternatives to the built 
food environment in low-income communities. So  

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these are a few steps for others to build on. 
In short, while our own desire for quick, tasty,  

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long-shelf-life foods helped build this broken 
food culture we've been trapped in for 50 years,  

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we are finally beginning to understand 
that it doesn't have to be this way.  

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Can we finally respond to the mounting burden of 
knowledge? If enough of us decide to make a better  

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food culture a United States priority, 
I'm confident that we can step by step,  

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rebuild our broken food culture, prevent a heck 
of a lot of disease, and live much better lives. 

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Thank you.

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DR. GORDON JENSEN: This is Gordon Jensen. I'm going to 
share a presentation with you that is an overview  

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in the medical setting regarding disease-related 
malnutrition. I'm the Senior Associate Dean for  

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Research Emeritus at the Robert Larner College 
of Medicine at The University of Vermont.  

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My objectives for this 20-minute overview 
is to talk a bit about where we have been,  

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provide a historical perspective, then 
shift to where we are now in regard to  

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00:31:19,740 --> 00:31:25,320
evolving approaches to screening, assessment, 
diagnosis, intervention, and monitoring, and  

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with particular focus on the contributions 
of disease and inflammation, and wrap up by  

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00:31:30,900 --> 00:31:35,880
talking about where we are going with 
key questions and research priorities.  

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So historical background, I'll really start with 
Jonathan Rhoads, who was the son of a Quaker  

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physician. He attended Haverford College 
and completed his M.D. at Johns Hopkins.  

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At the University of Pennsylvania, he served as 
the Chair of Surgery and Provost, and he was a  

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renowned researcher, scholar, and medical leader.
And he pioneered the development of intravenous  

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feeding, working with Stan Dudrick and Doug 
Wilmore on landmark studies in dogs and then  

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in humans. And I had the pleasure of having 
dinner some years ago with Jonathan Rhoads,  

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00:32:14,820 --> 00:32:24,420
and he was sharing stories with me of his early 
research studies, really a very exciting visit.  

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Other pioneers that helped to set the stage 
included Hiram Studley, who studied the  

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percentage of weight loss as a basic indicator 
of surgical risk in patients with chronic peptic  

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ulcer disease, with this landmark paper in JAMA 
in 1936. There are also some of my mentors,  

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Bruce Bistrian and George Blackburn at Harvard, 
that looked at the prevalence of malnutrition  

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in general surgical patients and general 
medical patients, and these two renowned  

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00:32:58,320 --> 00:33:09,480
JAMA presentations—papers from the 1970s. Other 
pioneers included John Waterlow and his classic  

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00:33:09,480 --> 00:33:16,560
paper on Classification and Definition of Protein 
Calorie Malnutrition in 1972; Charles Butterworth 

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00:33:16,560 --> 00:33:21,660
in his paper entitled "The Skeleton in the Hospital 
Closet", which was really a call to action 

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highlighting the high prevalence of malnutrition 
in hospital settings published in 1974;

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00:33:27,420 --> 00:33:34,200
and then Khursheed. Jeejeebhoy, still very much 
with us, very active, was the pioneer behind  

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00:33:34,200 --> 00:33:41,820
subjective global assessment that included 
metabolic stress as a disease component in  

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00:33:41,820 --> 00:33:50,220
assessment. Well, the settings for malnutrition 
across the globe have continued to evolve over  

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00:33:50,220 --> 00:33:56,760
time, and historically, famine and starvation 
were quite prevalent. There were also, you know,  

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00:33:56,760 --> 00:34:03,420
environmental catastrophes and wars. But today, 
we really face multiple burdens. Famine and  

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00:34:03,420 --> 00:34:09,120
starvation are still very much with us, but war 
and genocide continue, with food deprivation as a  

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00:34:09,120 --> 00:34:17,160
weapon, and malnutrition in the setting of disease 
or injury is now very prevalent across the globe.  

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So malnutrition now encompasses the full 
spectrum of undernutrition and overnutrition.  

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These two individuals shown on this slide 
are both malnourished, one with a profound  

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00:34:30,720 --> 00:34:36,780
temporal wasting and muscle loss, very severe 
undernutrition. The other patient with significant  

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00:34:36,780 --> 00:34:43,080
overnutrition, but is also malnourished 
with multiple micronutrient deficiencies. 

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00:34:44,400 --> 00:34:52,680
And we continue to have difficulties with refugees 
and displaced persons being at high risk for food  

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00:34:52,680 --> 00:35:00,660
insecurity and malnutrition. And the UN Refugee 
Agency in 2020 estimated that 82 million people  

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00:35:00,660 --> 00:35:06,720
have been forcibly displaced. And currently, 
and the war in Ukraine, more than 12 million  

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00:35:06,720 --> 00:35:15,420
people have had to flee their homes. So these 
very concerning issues continue. And of course,  

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00:35:15,420 --> 00:35:21,300
most recently, we have had the COVID-19 pandemic 
associated with food insecurity and malnutrition.  

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00:35:21,300 --> 00:35:27,000
Feeding America estimated that some 17 million 
Americans would become food insecure during the  

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00:35:27,000 --> 00:35:31,680
pandemic. And of course, there are issues 
with distancing, lockdowns, quarantines,  

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supply chain, loss of employment, cost of 
food. And these issues very much continue  

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today. And food insecurity and malnutrition are 
associated with the chronic diseases that place  

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people at higher risk for severe complications of 
COVID-19. And a high prevalence of malnutrition  

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00:35:47,760 --> 00:35:53,640
is found among hospitalized COVID-19 patients 
and is associated with increased mortality. 

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00:35:53,640 --> 00:36:00,000
The limitations of our historic approaches 
to thinking about diagnosis of malnutrition  

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00:36:00,000 --> 00:36:05,400
include use of criteria that lack full 
validity, limitations and specificity,  

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00:36:05,400 --> 00:36:12,720
sensitivity and inter-observer reliability, 
overlapping definitions of misdiagnosis, multiple  

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00:36:12,720 --> 00:36:18,540
definitions resulting in widespread confusion, 
and lack of a modern appreciation for the role  

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00:36:18,540 --> 00:36:28,440
of the inflammatory response. New insights over 
the past two decades include an understanding  

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00:36:28,440 --> 00:36:34,380
that the pathophysiology of malnutrition that 
is associated with disease or injury invariably  

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00:36:34,380 --> 00:36:39,420
consists of a combination of varying degrees 
of under or overnutrition and acute or chronic  

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00:36:39,420 --> 00:36:45,540
inflammation, leading to altered body composition 
and diminished biological function. In addition,  

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00:36:45,540 --> 00:36:51,420
disease-related malnutrition has been defined as 
the point at which the severity or persistence  

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00:36:51,420 --> 00:36:58,020
of inflammation results in a decrease in lean 
body mass associated with functional impairment.  

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00:37:01,860 --> 00:37:08,340
Disease-related malnutrition is associated with 
a host of poor outcomes, including increased  

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00:37:08,340 --> 00:37:14,340
mortality, increased complications, increased 
length of hospital stay, increased health care  

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00:37:14,340 --> 00:37:23,400
cost, and poor quality of life.
And thinking about this in a more  

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00:37:25,920 --> 00:37:33,720
expanded way, one can consider inflammation 
as an adaptive physiologic response versus  

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00:37:34,440 --> 00:37:40,500
self-destruction. And over the short run, indeed, 
inflammatory response can be quite adaptive to  

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00:37:40,500 --> 00:37:49,860
survive severe infections to mount the necessary 
response to get through a catastrophic injury. But  

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00:37:49,860 --> 00:37:57,480
when inflammation is sustained or severe, that 
is very much associated with adverse outcomes.  

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00:37:58,740 --> 00:38:05,880
And disease-associated inflammation promotes 
malnutrition and adverse outcomes. It promotes  

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00:38:05,880 --> 00:38:10,620
poor appetite, decreased nutrient intake, 
alters metabolism with elevated resting  

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00:38:10,620 --> 00:38:17,700
energy expenditure, and muscle catabolism with 
increased nitrogen excretion. It also results in  

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00:38:17,700 --> 00:38:23,520
altered micronutrient status and requirements. 
Some examples include iron, zinc, selenium,  

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00:38:23,520 --> 00:38:28,980
vitamin D, and vitamin A, but there are others. 
It also blunts the response to our nutrition  

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00:38:28,980 --> 00:38:38,040
interventions and makes them less efficacious. 
There's an interesting story I wanted to share  

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00:38:38,040 --> 00:38:44,520
with you from Merker and colleagues published in 
JAMA in Network Open in 2020, where they looked  

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00:38:44,520 --> 00:38:48,900
at the Association of Baseline Inflammation 
with the Effectiveness of Nutritional Support  

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00:38:48,900 --> 00:38:54,720
Among Patients with Disease-Related Malnutrition.
It was a secondary analysis of a randomized trial  

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00:38:54,720 --> 00:38:59,940
looking at early nutrition support on outcomes 
that included frailty, function, and recovery in  

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00:38:59,940 --> 00:39:05,520
eight Swiss hospitals, nearly 2,000 participants, 
all of whom had an admitting C-reactive protein.  

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00:39:05,520 --> 00:39:10,800
Compared to controls, those that received 
nutritional support had a significant reduction  

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00:39:10,800 --> 00:39:16,260
in 30-day mortality, regardless of CRP level. 
However, when you looked at people with very  

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00:39:16,260 --> 00:39:25,020
high inflammatory state, there was no beneficial 
effect of nutritional support on 30-day mortality.  

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00:39:26,280 --> 00:39:34,260
So, there's been a really robust effort to enhance 
diagnosis and characterization of malnutrition.  

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00:39:34,260 --> 00:39:41,280
There are several leading approaches available now 
that are in widespread use across the globe for  

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00:39:41,280 --> 00:39:49,980
diagnosing and evaluating malnutrition, including 
subjective global assessment. The Academy—ASPEN  

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00:39:49,980 --> 00:40:01,440
Indicators for Malnutrition, and the Global 
Leadership Initiative in Malnutrition. These are  

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00:40:01,440 --> 00:40:13,020
in widespread use across the globe, often subject 
to regional preferences and established usage. 

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00:40:13,020 --> 00:40:19,860
And you'll hear more about these 
throughout the three day workshop.  

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00:40:22,740 --> 00:40:31,740
Diagnosis can be related to underlying ideology, 
and this turns out to be fundamentally of  

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00:40:31,740 --> 00:40:36,420
importance. So you can consider malnutrition 
related to chronic disease with inflammation,  

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00:40:36,420 --> 00:40:42,180
malnutrition related to chronic disease of 
minimal or no perceived inflammation, malnutrition  

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00:40:42,180 --> 00:40:48,540
related to acute disease or injury with severe 
inflammation, and starvation related to hunger  

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00:40:48,540 --> 00:40:57,180
or food shortages associated with socioeconomic 
or environmental factors. Is it possible that  

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00:40:57,180 --> 00:41:03,060
we can use conditions that are associated with 
inflammation as proxy indicators for inflammation?  

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00:41:03,060 --> 00:41:09,240
This is something we are actively evaluating. 
So, you know, typical disorders associated with  

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00:41:09,240 --> 00:41:14,820
severe acute inflammatory response include 
critical illness, major infection or sepsis,  

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00:41:14,820 --> 00:41:22,320
ARDS, SIRS, severe burns, major abdominal surgery, 
multi-trauma, and closed head injury. More mild to  

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00:41:22,320 --> 00:41:27,060
moderate chronic inflammatory response can 
be associated with cardiovascular disease,  

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00:41:27,060 --> 00:41:35,580
congestive heart failure, COPD, Crohn's 
disease, diabetes, metabolic syndrome, dementia,  

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00:41:35,580 --> 00:41:44,160
and a host of other diseases or conditions.
If this approach was to work, it would  

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00:41:44,160 --> 00:41:53,160
require a relatively straightforward clinical 
recognition of the underlying disorder. Of course,  

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00:41:53,160 --> 00:42:02,940
it may suffer with issues in terms of sensitivity 
and specificity. Potential laboratory markers of  

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00:42:02,940 --> 00:42:10,020
inflammation certainly include C-reactive protein, 
which is perhaps the most used marker, but also  

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00:42:10,020 --> 00:42:15,900
interleukin six and procalcitonin. And indeed 
what were historically considered to be markers  

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00:42:15,900 --> 00:42:23,040
of protein malnutrition, albumin or prealbumin, 
are negative acute-phase reactants that are involved during  

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00:42:23,040 --> 00:42:29,280
inflammatory states. Immune dysfunction is another 
consideration, metabolic phenotyping, but there  

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00:42:29,280 --> 00:42:36,180
is a desperate need for improved laboratory 
markers of both malnutrition and inflammation.  

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00:42:37,860 --> 00:42:43,440
Other supporting assessments can include body 
composition, revealing decreased muscle mass;  

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00:42:43,440 --> 00:42:49,200
indirect calorimetry, revealing elevated resting 
energy expenditure; and clinical assessment,  

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00:42:49,200 --> 00:42:58,200
including fever, hypothermia, tachycardia, 
signs of muscle loss, and presence of edema. The  

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00:42:58,200 --> 00:43:05,940
key observation here is that nutrition support by 
itself in the study of robust active inflammation  

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00:43:05,940 --> 00:43:13,620
is not going to obviate a poor outcome.
It requires treatment of the underlying  

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00:43:13,620 --> 00:43:20,460
condition disorder or inflammatory 
state combined with nutrition care.  

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00:43:21,660 --> 00:43:27,840
There's interest in a host of potential 
interventions for inflammation, including  

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00:43:27,840 --> 00:43:37,020
anti-inflammatory medications; anti-cytokines; 
enhanced glycemic control; nutrition modulators,  

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00:43:37,020 --> 00:43:43,500
of course of particular interest to this audience; 
including n3 fatty acids; antioxidants; bioactive  

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00:43:43,500 --> 00:43:49,980
food components or modified diets; caloric 
restriction, and enteral preferred over parenteral  

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00:43:49,980 --> 00:43:56,340
nutrition support. There's also probiotics 
and also physical activity and weight loss.  

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00:43:58,920 --> 00:44:05,550
So conclusions to take away from my short overview 
would be that malnutrition in the setting of  

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00:44:05,550 --> 00:44:10,260
disease is different. Two, disease-related 
malnutrition is common in health care and  

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00:44:10,260 --> 00:44:14,400
other settings. Three, that disease-related 
malnutrition is associated with poor medical  

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00:44:14,400 --> 00:44:20,400
treatment outcomes. And four, that disease related 
malnutrition requires both treatment of underlying  

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00:44:20,400 --> 00:44:26,580
disease and nutrition intervention. 
And to wrap up with some quick comments  

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00:44:26,580 --> 00:44:32,340
regarding research priorities and questions,
number one, can we fully integrate screening,  

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00:44:32,340 --> 00:44:38,100
assessment, intervention, and monitoring 
to promote improved outcomes? At present,  

378
00:44:38,100 --> 00:44:47,520
it is very common for these not to be integrated 
in a meaningful intervention, especially with the  

379
00:44:48,120 --> 00:44:55,080
transitions to outside-of-hospital care. Can we 
develop standardized approaches to diagnosis and  

380
00:44:55,080 --> 00:45:02,460
data reporting so that we can compare prevalence 
of malnutrition, as well as interventions and  

381
00:45:02,460 --> 00:45:07,140
associated outcomes? Can we better train 
practitioners? I think in particular there  

382
00:45:07,140 --> 00:45:12,600
is a priority to develop a validated approach to 
diagnosis that incorporates key core variables  

383
00:45:12,600 --> 00:45:19,080
that are amenable to use by practitioners with 
limited nutrition expertise or resources. An  

384
00:45:19,080 --> 00:45:25,620
example of an approach in this direction would be 
the Global Leadership Initiative in Malnutrition.  

385
00:45:26,460 --> 00:45:34,320
And there also should be opportunity for a 
streamlined hybrid approach to integrate screening  

386
00:45:34,320 --> 00:45:39,960
and assessment components for a preliminary of 
diagnosis of malnutrition. And in settings where  

387
00:45:39,960 --> 00:45:46,260
feasible, this should trigger comprehensive 
assessment, promoting better integration. 

388
00:45:48,300 --> 00:45:52,620
Some additional priorities and questions. 
Biomarker panels are needed to support  

389
00:45:52,620 --> 00:45:58,560
diagnosis and monitoring of undernutrition and 
inflammation. Technology development is needed  

390
00:45:58,560 --> 00:46:03,960
to provide portable, valid, reliable, inexpensive 
assessment of muscle mass and function that is  

391
00:46:03,960 --> 00:46:11,520
applicable to diverse care settings. Appropriate 
and useful outcome measures are needed. Mortality,  

392
00:46:11,520 --> 00:46:16,800
length of stay, complications, and readmission are 
complex multivariable outcomes that are impacted  

393
00:46:16,800 --> 00:46:23,340
by many other variables besides nutritional 
status. Now, is there potential to develop  

394
00:46:23,340 --> 00:46:29,400
tailored population-level and disease-specific 
interventions? These warrant further evaluations,  

395
00:46:29,400 --> 00:46:34,260
and to begin with, we should probably focus 
our initial research efforts on those types  

396
00:46:34,260 --> 00:46:39,540
of patients that we believe are most likely 
to accrue benefits from such nutritional  

397
00:46:39,540 --> 00:46:46,800
support. And I thank you for your attention, 
and I'm looking forward to an exciting series  

398
00:46:46,800 --> 00:46:52,680
of presentations throughout the workshop 
over these 3 days. Have a great day.

399
00:46:52,680 --> 00:47:07,080
DR. MARION WINKLER: My name is Marion Winkler. The objective of my 
presentation today is to provide an overview of  

400
00:47:07,080 --> 00:47:13,500
the Agency for Healthcare Research and Quality 
Report on Malnutrition in Hospitalized Adults.  

401
00:47:15,180 --> 00:47:23,460
Congress requested in fiscal year 2020 that the 
Agency for Healthcare Research and Quality convene  

402
00:47:23,460 --> 00:47:31,260
a panel of experts charged with developing quality 
measures for malnutrition-related readmissions.  

403
00:47:31,260 --> 00:47:38,100
These measures were intended to support assigning 
accountability for the assessment and treatment  

404
00:47:38,100 --> 00:47:45,540
of malnutrition in hospitalized adults, with an 
emphasis on the needs of older, frail adults.  

405
00:47:46,080 --> 00:47:53,100
The Evidence Practice Center worked with a panel 
of technical and content experts, some of whom  

406
00:47:53,100 --> 00:48:00,300
are speaking at this virtual conference. The 
final evidence report underwent simultaneous  

407
00:48:00,300 --> 00:48:09,000
independent peer review and public comment. And 
my role in this project was as a peer reviewer.  

408
00:48:09,660 --> 00:48:17,880
The investigators conducted a systematic review 
of research published between January 1, 2000,  

409
00:48:18,660 --> 00:48:28,860
and June 3, 2021. Using predefined criteria 
focused on adults aged 18 years or older,  

410
00:48:28,860 --> 00:48:35,520
the search did include existing systematic 
reviews that assessed associations between  

411
00:48:35,520 --> 00:48:40,680
malnutrition and clinical outcomes, 
randomized and nonrandomized studies  

412
00:48:41,520 --> 00:48:48,180
evaluating the effectiveness of screening or 
diagnostic nutrition assessment on clinical  

413
00:48:48,180 --> 00:48:54,780
outcomes, and RCTs assessing hospital- 
initiated treatments for malnutrition. 

414
00:48:54,780 --> 00:49:01,500
Meta-analyses were conducted when appropriate 
to quantitatively summarize study findings,  

415
00:49:01,500 --> 00:49:08,940
otherwise, the data were narratively synthesized. 
And when available, pooled estimates from existing  

416
00:49:08,940 --> 00:49:15,120
systematic reviews were also used to determine 
association between malnutrition and clinical  

417
00:49:15,120 --> 00:49:22,080
outcomes, as well as to assess the strength of 
evidence. All of the data synthesis was performed  

418
00:49:22,080 --> 00:49:29,520
using the AHRQ Methods Guide for Effectiveness 
and Comparative Effectiveness Reviews.  

419
00:49:32,100 --> 00:49:40,980
Malnutrition was defined based on common 
diagnostic tools, such as SGA or MNA,  

420
00:49:40,980 --> 00:49:48,300
and the screening tools, such as the Geriatric 
Nutritional Risk Index, the Malnutrition Universal  

421
00:49:48,300 --> 00:49:57,240
Screening Tool, and the NRS-2002. Interventions 
of interest included treatments initiated within  

422
00:49:57,240 --> 00:50:05,520
hospital and intended to impact nutritional status, 
such as specialized nutrition care, which was  

423
00:50:05,520 --> 00:50:11,220
described as referral to a registered dietitian 
or consultation with a nutrition specialist,  

424
00:50:11,220 --> 00:50:17,400
as well as increased protein and calorie 
provision through oral nutrition supplementation,  

425
00:50:17,400 --> 00:50:25,800
energy-dense supplements or fortified meals.
The studies did not include enteral or parenteral  

426
00:50:25,800 --> 00:50:34,740
nutrition, primarily because these intervention 
trials did not define diet malnutrition using a  

427
00:50:34,740 --> 00:50:41,520
common diagnostic assessment tool. The clinical 
outcomes of interest included mortality,  

428
00:50:41,520 --> 00:50:48,540
length of hospital stay, 30-day readmission, 
quality of life, functional status, activities  

429
00:50:48,540 --> 00:50:54,600
of daily living, hospital-acquired conditions, 
wound healing, and discharge disposition.  

430
00:50:55,560 --> 00:51:02,820
There were three key questions addressed. Key 
question number one, what is the association  

431
00:51:02,820 --> 00:51:08,760
between malnutrition and clinical outcomes 
among hospitalized patients? Key question two,  

432
00:51:08,760 --> 00:51:13,980
what is the effectiveness of screening or 
diagnostic assessment for malnutrition?  

433
00:51:13,980 --> 00:51:20,040
And key question three, among patients 
diagnosed with malnutrition, what is the  

434
00:51:20,040 --> 00:51:24,840
effectiveness of hospital-initiated 
interventions to treat malnutrition?  

435
00:51:27,180 --> 00:51:35,640
In this study flow diagram, you can see that the 
electronic searches identified 3,308 citations,  

436
00:51:35,640 --> 00:51:44,940
of which 83 required full-text review. Overall, 
17 studies met the eligibility criteria for  

437
00:51:44,940 --> 00:51:51,240
inclusion, including six systematic 
reviews to address key question one. 

438
00:51:51,840 --> 00:51:58,200
There were no studies that met the inclusion 
criteria to address key question two, that's  

439
00:51:58,200 --> 00:52:06,060
the effectiveness of screening on hospitalized 
adults. And there were 11 RCTs included to answer  

440
00:52:06,060 --> 00:52:12,540
key question three regarding the effectiveness 
of interventions used to treat malnutrition.  

441
00:52:12,540 --> 00:52:20,460
The primary reasons for exclusion related to 
wrong patient population not being hospitalized,  

442
00:52:21,720 --> 00:52:27,000
lack of definition or diagnosis of 
malnutrition with an appropriate tool,  

443
00:52:27,000 --> 00:52:34,560
study design or the wrong geographical setting. 
And most of the studies in the systematic  

444
00:52:34,560 --> 00:52:42,540
reviews were prospective cohort trials, and the 
patients were hospitalized for traumatic injury,  

445
00:52:42,540 --> 00:52:48,660
acute medical conditions requiring ICU 
level of care, heart failure, cancer,  

446
00:52:48,660 --> 00:52:53,160
COPD, and cirrhosis awaiting liver transplantation.  

447
00:52:54,960 --> 00:53:01,740
Now, the findings for...to answer key question one, 
which was the association between malnutrition  

448
00:53:01,740 --> 00:53:09,720
and clinical outcomes...in general, the findings 
included that ICU patients screened or diagnosed  

449
00:53:09,720 --> 00:53:15,660
with malnutrition may have higher hospital 
mortality compared to well-nourished patients. 

450
00:53:15,660 --> 00:53:21,600
Malnutrition was independently associated with 
prolonged hospital length of stay among patients  

451
00:53:21,600 --> 00:53:27,540
with acute medical conditions or cancer, and 
that malnutrition was associated with increased  

452
00:53:27,540 --> 00:53:33,960
hospital-acquired conditions among patients with 
trauma or acute medical conditions compared to  

453
00:53:33,960 --> 00:53:38,760
well-nourished patients. And you can see the 
overall standard of the evidence being low.  

454
00:53:40,080 --> 00:53:46,500
As mentioned earlier regarding key question two 
in terms of clinical utility or effectiveness  

455
00:53:46,500 --> 00:53:54,780
of screening, there were no studies included. 
They lacked...they did not meet the inclusion criteria.  

456
00:53:54,780 --> 00:54:00,960
And the primary reason was the lack of an 
appropriate control group. Regarding key question  

457
00:54:00,960 --> 00:54:08,280
three the effectiveness of hospital-initiated 
malnutrition interventions compared to usual care,  

458
00:54:08,280 --> 00:54:15,540
these interventions, likely decrease mortality 
and may actually improve quality of life,  

459
00:54:15,540 --> 00:54:23,100
which was measured by the EuroQol or the Short 
Form 36. There was no difference observed between  

460
00:54:23,100 --> 00:54:29,880
interventions and usual care for length of stay, 
readmission rates, or hospital acquired conditions,  

461
00:54:29,880 --> 00:54:36,540
and evidence was insufficient to address effect 
of interventions on activities of daily living  

462
00:54:36,540 --> 00:54:45,420
and discharge disposition compared to usual care.
So overall, the review confirmed that malnutrition  

463
00:54:45,420 --> 00:54:52,320
defined by commonly available measurement tools 
is associated with poor clinical outcomes. And  

464
00:54:52,320 --> 00:54:58,380
the review found no studies to assess whether 
malnutrition, screening, or diagnostic assessment  

465
00:54:58,380 --> 00:55:05,760
actually prompts actions that change either 
nutritional stores or these key clinical outcomes  

466
00:55:05,760 --> 00:55:15,060
of interest. The review did find moderate evidence 
from 11 RCTs that hospital-initiated specialized  

467
00:55:15,060 --> 00:55:22,440
nutrition care and increased protein calorie 
provision likely reduces mortality compared to  

468
00:55:22,440 --> 00:55:30,000
usual care and may improve quality of life. The 
review does, however, underscore the many known  

469
00:55:30,000 --> 00:55:36,180
limitations of research on nutritional measurement 
tools, including the very definitions of  

470
00:55:36,180 --> 00:55:45,540
malnutrition and reliance on disease, weight loss, 
body mass index, and other biomarkers, such as serum  

471
00:55:45,540 --> 00:55:52,980
albumin, as proxies for malnutrition, diagnosis, 
or clinical opinion to define malnutrition.  

472
00:55:53,820 --> 00:56:00,120
There were also very few studies that aligned with 
the Global Leadership Initiative on Malnutrition,  

473
00:56:00,120 --> 00:56:07,080
the GLIM consensus criteria, although this likely 
relates to the time frame that was studied. 

474
00:56:07,620 --> 00:56:13,920
Overall, the review acknowledges the known 
variation in measurement tools regarding  

475
00:56:13,920 --> 00:56:19,980
validity and reliability. And finally, there 
was a high risk of bias and poor reporting  

476
00:56:19,980 --> 00:56:27,420
of adverse events in the intervention trials. 
Well, the Agency for Healthcare Research and  

477
00:56:27,420 --> 00:56:33,540
Quality Report on Malnutrition in Hospitalized 
Adults identified a number of clinical practice,  

478
00:56:33,540 --> 00:56:39,660
knowledge, and research gaps. And the 
authors highlight a gold standard is  

479
00:56:39,660 --> 00:56:46,260
really necessary to support future clinical 
care and research for defining malnutrition.  

480
00:56:46,980 --> 00:56:55,740
Future studies should stratify patients by age, 
gender, and frailty. And the absence of studies  

481
00:56:55,740 --> 00:57:02,160
addressing the clinical utility or effectiveness 
of measurement tools for both nutrition screening  

482
00:57:02,160 --> 00:57:07,860
and diagnostic assessment does not imply 
that these tools are ineffective. Rather,  

483
00:57:07,860 --> 00:57:14,640
it reveals the need for appropriately designed 
studies to better understand the downstream  

484
00:57:14,640 --> 00:57:22,140
consequences of screening, assessment, management, 
and clinical outcomes, specifically because of the  

485
00:57:22,140 --> 00:57:28,740
hospital mandate in the United States to screen 
for nutrition risk within 24 hours of admission. 

486
00:57:29,820 --> 00:57:35,940
Now, future research should also support 
the identification of which variables in  

487
00:57:35,940 --> 00:57:41,760
the measurement tools have the greatest impact 
on sensitivity and specificity in prospective  

488
00:57:41,760 --> 00:57:47,880
clinical trials, and future studies should also 
randomize patients diagnosed with malnutrition  

489
00:57:47,880 --> 00:57:56,400
to different interventions, including parenteral 
and enteral nutrition, and do subgroup analysis to  

490
00:57:56,400 --> 00:58:02,760
assess the benefits of nutritional intervention 
and document harms associated with treatment.  

491
00:58:02,760 --> 00:58:10,320
And finally, further research in this area 
is essential to determine which malnourished  

492
00:58:10,320 --> 00:58:17,400
patient populations benefit from specific types of 
interventions, and key guidance for hospitals is  

493
00:58:17,400 --> 00:58:25,500
needed to standardize the processes for screening, 
diagnosing, and documenting malnutrition in order  

494
00:58:25,500 --> 00:58:32,040
to inform development of quality measures 
and improved patient outcomes. Thank you.

495
00:58:32,040 --> 00:58:40,200
DR. PEGGI GUENTER: Good afternoon. My name is Peggi 
Guenter from the American Society for Parenteral  

496
00:58:40,200 --> 00:58:45,600
and Enteral Nutrition. And today I will be 
speaking to you about the ASPEN Value Project.  

497
00:58:48,180 --> 00:58:53,580
We know that health care leaders are looking 
for guidance on prudent investment in  

498
00:58:53,580 --> 00:58:59,760
programs and resources that improve the patient 
experience, reduce hospital acquired conditions,  

499
00:58:59,760 --> 00:59:08,940
reduce length of stay, and decrease readmissions. 
In 2017, ASPEN projected the need to expand our  

500
00:59:08,940 --> 00:59:16,560
role from an organization promoting utilization 
of specialty nutrition services to one that also  

501
00:59:16,560 --> 00:59:23,700
clearly was articulating the value proposition 
for nutrition support across the continuum.  

502
00:59:23,700 --> 00:59:28,320
This project meets several of 
those goals of our strategic plan.  

503
00:59:31,380 --> 00:59:37,740
The goals of the value project were to describe 
the impact of nutrition care, particularly related  

504
00:59:37,740 --> 00:59:44,220
to specific conditions on health care costs 
and resource utilization, to provide economic  

505
00:59:44,220 --> 00:59:50,820
evidence to demonstrate the impact nutrition has 
on patient outcomes in specific therapeutic areas,  

506
00:59:50,820 --> 00:59:56,940
and to provide ASPEN members and stakeholders 
more effective messaging to communicate  

507
00:59:56,940 --> 01:00:03,480
with key health care decision-makers, such as 
administrators, providers, payers, and regulators. 

508
01:00:06,180 --> 01:00:11,700
Our plan for this project came in three 
parts, and for this we partnered with  

509
01:00:11,700 --> 01:00:18,000
Avalere Health. Part one was the nutrition 
care outcomes targeted literature review.  

510
01:00:19,380 --> 01:00:23,880
Part two, the analysis of cost 
data using Medicare claims.  

511
01:00:24,660 --> 01:00:30,660
And three, development of the value messaging 
for the top five to eight impact conditions.  

512
01:00:34,260 --> 01:00:41,580
So for part one, our approach was conducting 
a targeted literature review. And for that,  

513
01:00:41,580 --> 01:00:49,020
we used publicly available evidence through April 
of 2018. That literature should be reflective of  

514
01:00:49,020 --> 01:00:55,800
the impact of nutrition care on patient clinical 
and cost outcomes. It should include high-impact  

515
01:00:55,800 --> 01:01:02,820
conditions in all care settings. And also, we 
used general nutrition care search terms and  

516
01:01:02,820 --> 01:01:09,120
disease-specific search terms as directed 
by the ASPEN Scientific Advisory Council.  

517
01:01:10,980 --> 01:01:18,660
Our overall results from that literature 
search were that there was high variability  

518
01:01:18,660 --> 01:01:24,420
in the quality of evidence, and most study 
endpoints focused solely on clinical outcomes.  

519
01:01:25,260 --> 01:01:30,180
Specifically, the literature consisted 
of mostly moderate-quality evidence. 

520
01:01:30,900 --> 01:01:37,080
Over 70% of the articles reported 
were only clinical outcomes. Over  

521
01:01:37,080 --> 01:01:42,240
70% of the articles assessed oral 
nutrition supplements, enteral and  

522
01:01:42,240 --> 01:01:48,900
parenteral interventions. And about 75% of the 
articles reported studies at a single site.  

523
01:01:49,620 --> 01:01:55,860
We found there were only five level-one grade 
articles that were based in the United States.  

524
01:01:59,340 --> 01:02:08,460
So from this, the Value Project Scientific 
Advisory Council examined eight top therapeutic  

525
01:02:08,460 --> 01:02:15,420
areas to select five for our part two or the 
Medicare analysis. Our questions were which  

526
01:02:15,420 --> 01:02:23,520
ones are homogeneous and could be analyzed, which 
could be most impactful, and which ones already had  

527
01:02:23,520 --> 01:02:31,200
some claims data research? So from the literature, 
we came up with five for the Medicare claims that  

528
01:02:31,200 --> 01:02:38,940
was pancreatitis, sepsis, GI cancer, hospital-acquired conditions, and surgical complications.  

529
01:02:41,280 --> 01:02:49,740
So we started with 1,099 studies. In the 13 
original therapeutic areas, we found 114  

530
01:02:49,740 --> 01:02:57,960
papers that had clinical and/or cost outcomes 
measured. In the eight selected therapeutic  

531
01:02:57,960 --> 01:03:03,900
areas with literature that was evaluated to be 
strong, we narrowed that down to 81 studies. 

532
01:03:04,620 --> 01:03:12,060
Then in the five therapeutic areas, we found 43 
studies, then removed many due to the following  

533
01:03:12,060 --> 01:03:17,880
factors and ended up with eight studies 
to use for part two. Some of the reasons  

534
01:03:17,880 --> 01:03:23,640
to remove studies were that the factors may 
not have been observable or measurable in the  

535
01:03:23,640 --> 01:03:31,320
Medicare database; that the study compared several 
different interventions; such as EN versus PN;  

536
01:03:32,460 --> 01:03:38,340
that they were duplicative of other studies; or 
that they were not focused on an intervention.  

537
01:03:42,240 --> 01:03:47,220
So our objective of part two is 
to understand the real-world cost  

538
01:03:47,220 --> 01:03:52,200
impacts of nutrition care services in 
the five selected therapeutic areas.  

539
01:03:53,580 --> 01:03:58,080
We wanted to identify the maximum amount 
of savings to the Medicare program  

540
01:03:58,920 --> 01:04:06,420
based on modeling findings described in those 
studies. Our studies included in part one were  

541
01:04:06,420 --> 01:04:13,260
assessed for feasibility of modeling their 
reported outcomes onto Medicare Part A and B  

542
01:04:13,260 --> 01:04:19,740
claims and for those where study components could 
be modeled, annualized savings were projected.  

543
01:04:20,340 --> 01:04:26,640
We were using ICD-10 codes to identify the 
study populations and assign conditions. 

544
01:04:26,640 --> 01:04:33,660
And we are applying the study results and 
extrapolating cost savings. For each included  

545
01:04:33,660 --> 01:04:40,320
study, applying findings to the defined population 
and measuring savings associated with reduced  

546
01:04:40,320 --> 01:04:47,700
adverse outcomes or research utilization, such as 
a lower length of stay or reduced complications.  

547
01:04:50,400 --> 01:04:55,680
So we utilize the Medicare fee-for- 
service Parts A and B claims the  

548
01:04:55,680 --> 01:05:01,380
5% sample database. The 5% sample, 
as is known...is recognized as being  

549
01:05:01,380 --> 01:05:06,660
statistically representative of the entire 
Medicare population and could be roughly  

550
01:05:06,660 --> 01:05:13,020
adjusted to the full 100% population 
by multiplying raw results by 20.  

551
01:05:13,680 --> 01:05:20,880
Sample database include costs from inpatient and 
post-acute care. And then, once the savings were  

552
01:05:20,880 --> 01:05:26,220
calculated based on the raw sample data, the 
results were adjusted to the full population  

553
01:05:26,220 --> 01:05:32,400
and further adjusted the results to describe 
the average annual effects of the intervention.  

554
01:05:36,060 --> 01:05:42,840
So here is an example of how we did the modeling 
based on one study in septic patients with ARDS  

555
01:05:42,840 --> 01:05:50,820
on the ventilator and on enteral nutrition.
We pulled 33 months of Medicare 5% sample  

556
01:05:50,820 --> 01:06:00,420
from October 2015 to June of 2018. Using ICD-10 
codes, we limited it to patients with these  

557
01:06:00,420 --> 01:06:06,840
conditions who are also receiving tube feeding. 
And we found 309 patients who met these criteria.  

558
01:06:07,500 --> 01:06:13,020
We then applied the study results. For 
instance, in this study it was reported  

559
01:06:13,020 --> 01:06:22,980
a 38% reduction of length of stay. And with 
309 cases, we found average about nine cases  

560
01:06:22,980 --> 01:06:29,100
per month in that 5% sample. The cost savings 
of that potential decreased length of stay— 

561
01:06:29,100 --> 01:06:38,700
$23,000 per patient—was applied to the nine 
patients per month, yielding $215,000 for all  

562
01:06:38,700 --> 01:06:47,400
nine patients. We then multiply it by 12 to get 
the annual savings, which was about $2.58 million.  

563
01:06:47,400 --> 01:06:56,160
We then extrapolated that 5% sample to 100%, and 
that went up to $52 million in annual savings.  

564
01:06:56,760 --> 01:07:03,000
This is a reflection of the upper limits of 
possible savings to Medicare in a year if  

565
01:07:03,000 --> 01:07:09,240
the length of stay could be reduced in all these 
possible patients that met the study criteria.  

566
01:07:12,300 --> 01:07:19,560
So what we ended up with looking at sepsis, 
GI cancer, hospital-acquired conditions, and  

567
01:07:19,560 --> 01:07:26,880
surgical complications was an applicable 
cost reduction of about $582 million. 

568
01:07:28,560 --> 01:07:34,140
Some of these studies were 
looking at different outcomes,  

569
01:07:34,140 --> 01:07:38,280
and so that's where we got the different 
studies with the different cost savings.  

570
01:07:41,700 --> 01:07:49,020
Here is our report published in the 2020 Journal 
of Parenteral and Enteral Nutrition on the findings  

571
01:07:49,020 --> 01:07:58,140
of this project. We also had the data pulled on 
coded malnutrition in these patients. You can see,  

572
01:07:58,140 --> 01:08:05,880
for instance, based on a study of esophageal 
cancer patients and surgery, there were 8,179  

573
01:08:05,880 --> 01:08:14,820
patients in the Medicare database. Twenty-one percent had a coded 
diagnosis of malnutrition. And of those, only 15%  

574
01:08:14,820 --> 01:08:25,380
received enteral nutrition. These malnutrition 
rates range from 14 to 30%, and yet only 2 to 16%  

575
01:08:25,380 --> 01:08:31,260
of those with malnutrition received nutrition 
support. This again shows the need for better  

576
01:08:31,260 --> 01:08:37,680
diagnosing and coding malnutrition and appropriate 
application of nutrition support interventions.  

577
01:08:40,140 --> 01:08:46,560
The Value Project Work Group published an 
additional two papers, one on GI cancer data  

578
01:08:46,560 --> 01:08:53,040
by Dr. Pimiento and one on hospital-acquired 
infection analysis by Dr. Matt Bechtold.  

579
01:08:54,180 --> 01:08:58,500
Looking to future research, one 
thing was clear from this project  

580
01:08:58,500 --> 01:09:01,680
was there are not enough studies 
that look at value and financial  

581
01:09:01,680 --> 01:09:06,660
implications of nutrition support with 
their impact...its impact on outcome. 

582
01:09:06,660 --> 01:09:12,180
A few learnings that we suggest be 
included in the future research are;  

583
01:09:12,960 --> 01:09:19,320
use of homogeneous patient populations, 
report the cost of nutrition support services,  

584
01:09:21,180 --> 01:09:27,960
produce evidence around net savings in terms of 
health care costs, collect and report data on  

585
01:09:27,960 --> 01:09:33,540
reductions in readmissions or complication 
avoidance as a outcome to show value,  

586
01:09:34,200 --> 01:09:39,000
and explicitly capture information 
on malnutrition diagnosis to better  

587
01:09:39,000 --> 01:09:43,440
characterize the incremental value 
of treating this subpopulation.  

588
01:09:48,060 --> 01:09:53,040
Partial funding for the ASPEN Value Project 
was supported by these industry partners.  

589
01:09:54,660 --> 01:10:01,500
Here are my references, and thank you so much for 
the opportunity to speak with you on this topic.

590
01:10:04,760 --> 01:10:09,360
DR. KRISTI MITCHELL: Good afternoon. Thank you 
again for the opportunity to share  

591
01:10:09,360 --> 01:10:12,300
the development of the Malnutrition 
Quality Improvement Initiative,  

592
01:10:12,300 --> 01:10:19,080
also known as the MQii, interesting findings 
from our data and how such an initiative can  

593
01:10:19,080 --> 01:10:24,840
accelerate optimal malnutrition quality of care 
both in and outside of the acute care setting.  

594
01:10:27,540 --> 01:10:31,800
During today's presentation, I will 
briefly walk you through the MQii,  

595
01:10:31,800 --> 01:10:37,560
our experience in quality measure development 
and adoption, and I'll outline how it has served  

596
01:10:37,560 --> 01:10:42,120
as the foundation for driving malnutrition 
quality of care across hospitals throughout  

597
01:10:42,120 --> 01:10:45,720
the country. I look forward to sharing some 
lessons learned from our research over the  

598
01:10:45,720 --> 01:10:50,160
last few years and then tee up what's next on 
the horizon for this national initiative.  

599
01:10:50,160 --> 01:10:54,840
Finally, I want to lift up for consideration 
future research opportunities to expand on  

600
01:10:54,840 --> 01:10:58,800
evidence base and potentially close 
some knowledge gaps in the space.  

601
01:11:03,000 --> 01:11:07,980
As with all presentations about malnutrition, 
there is a need to level set around why it  

602
01:11:07,980 --> 01:11:11,940
matters. With this audience, I don't need to 
go into the details presented on this slide,  

603
01:11:11,940 --> 01:11:15,480
but to state that the ground has 
been set for the need to raise  

604
01:11:15,480 --> 01:11:20,340
awareness and implement interventions 
to advance evidence-based, high-quality,  

605
01:11:20,340 --> 01:11:24,420
patient-driven care for hospitalized 
older adults who are malnourished. 

606
01:11:27,900 --> 01:11:32,760
To answer this call for action, in 2013, 
the Academy of Nutrition and Dietetics,  

607
01:11:32,760 --> 01:11:39,780
along with Avalere Health and other stakeholders, 
developed and implemented the MQii as a national  

608
01:11:39,780 --> 01:11:45,240
QI program. I am fortunate to have been involved 
with this initiative since its inception.  

609
01:11:46,080 --> 01:11:51,480
Our aim has been to improve care and outcomes 
for hospitalized adults aged 65 and older 

610
01:11:51,480 --> 01:11:54,540
with a series of nutrition-focused QI innovations,  

611
01:11:55,560 --> 01:12:02,340
including the development of an interdisciplinary 
QI toolkit that's available online for anyone to  

612
01:12:02,340 --> 01:12:07,620
use. Two, the establishment of a national 
Learning Collaborative. And three,  

613
01:12:07,620 --> 01:12:14,100
the development of the first set of malnutrition 
electronic clinical quality measures or eCQMs.  

614
01:12:14,700 --> 01:12:19,680
We provided this dual-pronged approach, largely 
based upon feedback from the hospital community,  

615
01:12:19,680 --> 01:12:25,140
begging for no new measures without 
providing tools to help them improve.  

616
01:12:28,800 --> 01:12:33,480
As the crown jewel of our initiative, we 
launched the Learning Collaborative with seven  

617
01:12:33,480 --> 01:12:41,520
participating hospitals in 2015. It has since 
expanded to a 314-member network across the U.S.  

618
01:12:41,520 --> 01:12:46,560
located in 38 states and Puerto Rico, 
representing dozens of health systems. 

619
01:12:47,160 --> 01:12:51,900
There has been a tremendous groundswell of 
support across the U.S. that has catapulted us  

620
01:12:51,900 --> 01:12:57,540
towards success. Of note, interest in engaging 
in this initiative has spread globally.  

621
01:12:57,540 --> 01:13:03,240
In 2018, we answered a call from the National 
Health Service to adopt the toolkit and our  

622
01:13:03,240 --> 01:13:08,220
quality measures across a number of health 
trusts in the U.K. What a great testament to  

623
01:13:08,220 --> 01:13:13,740
the power of this approach. More importantly, 
what a unique research opportunity to compare  

624
01:13:13,740 --> 01:13:18,480
and contrast clinical performance against 
a standardized set of quality measures.  

625
01:13:21,960 --> 01:13:25,560
Measurement overall is necessary 
if you truly seek to improve. 

626
01:13:25,560 --> 01:13:30,240
As Peter Drucker would say, "If you 
can't measure it you can't manage it."  

627
01:13:30,240 --> 01:13:36,300
On this slide, you will see that it's taken quite 
some time to develop, test, receive endorsement  

628
01:13:36,300 --> 01:13:41,460
from the National Quality Forum, and finally gain 
national adoption into a CMS reporting program.  

629
01:13:42,180 --> 01:13:48,540
This road has been bumpy, but it has certainly 
paid off. At the end of this journey, we now have  

630
01:13:48,540 --> 01:13:59,340
four individual eCQMs that mirror the nutrition 
care process and one new global composite measure  

631
01:13:59,340 --> 01:14:04,560
that has been adopted by CMS for inclusion 
in its inpatient quality reporting program. 

632
01:14:07,980 --> 01:14:14,640
So what does this all mean? What is this composite 
score? I want to quickly call your attention to  

633
01:14:14,640 --> 01:14:20,040
the four components of the global malnutrition 
composite score and highlight that it is indeed  

634
01:14:20,040 --> 01:14:26,640
the first electronic global measure that's ever 
been adopted by CMS for accountability. That is,  

635
01:14:26,640 --> 01:14:30,960
hospitals can voluntarily select this measure 
to meet their requirement for value-based  

636
01:14:30,960 --> 01:14:36,420
reimbursement. We see this as a huge win for the 
community and an even bigger win for patients.  

637
01:14:39,840 --> 01:14:45,600
While we were moving quality measurement 
along on the national level, 90 plus  

638
01:14:45,600 --> 01:14:55,020
hospitals participated in routinely capturing 
the same for eCQMs screening, assessment,  

639
01:14:55,020 --> 01:15:01,140
diagnosis, and the establishment of a care plan 
on a local level. Upon sending us their data, we  

640
01:15:01,140 --> 01:15:06,240
provided these hospitals with quarterly benchmark 
reports for them to track and monitor their own  

641
01:15:06,240 --> 01:15:12,240
performance against their peers. To date, we 
have well over 1.5 million patient records  

642
01:15:12,240 --> 01:15:19,020
detailing nutrition care and have published well 
over 30 papers about our experience to date. 

643
01:15:19,980 --> 01:15:27,120
Of note, one paper published in JPEN in 
2021 detailed the experience of 27 hospitals  

644
01:15:27,120 --> 01:15:34,080
participating in the MQii. Multivariate analysis 
were conducted across 43,000 unique patients,  

645
01:15:34,080 --> 01:15:40,500
and improvements were observed across all four 
of those eCQMs. The greatest improvement was  

646
01:15:40,500 --> 01:15:49,740
in timely nutrition assessment and malnutrition 
diagnosis. Most notably, patients over 65 with  

647
01:15:49,740 --> 01:15:55,860
a malnutrition diagnosis and a care plan had 
a 24% lower likelihood of 30-day readmission.  

648
01:15:56,580 --> 01:16:01,440
But the same population had a longer mean length 
of stay than those who did not have a care plan.  

649
01:16:01,440 --> 01:16:06,900
Overall, we found that the implementation 
of the MQii practices significantly improved  

650
01:16:06,900 --> 01:16:14,700
the identification of malnutrition. Similarly, 
hospitals within our network have also published  

651
01:16:14,700 --> 01:16:20,700
on their experiences. Tampa General Hospital 
is one such example, using the toolkit in a  

652
01:16:20,700 --> 01:16:26,400
multi-pronged approach creating interdisciplinary 
teams of staff, they identified gaps in care that  

653
01:16:26,400 --> 01:16:30,660
could be improved through a series of changes 
to their hospital-wide clinical workflow. 

654
01:16:30,660 --> 01:16:34,440
Following this implementation over 
a 7 or 8 months or so,  

655
01:16:35,040 --> 01:16:43,920
these QI processes led to a 25% reduction 
in length of stay and a 36% reduction in  

656
01:16:43,920 --> 01:16:48,060
infection rate. This study adds to 
a growing body of literature on QI  

657
01:16:48,060 --> 01:16:52,920
processes that can be undertaken to better 
identify and treat malnourished patients.  

658
01:16:56,940 --> 01:17:02,580
Given the intense interest in reducing health 
disparities and advancing health equity, I want  

659
01:17:02,580 --> 01:17:07,980
to share some contemporary data from our learning 
collaborative sites. Recent analyses demonstrate  

660
01:17:07,980 --> 01:17:15,900
wide variation in eCQM and outcome measures 
across age, race, ethnicity, and rural versus urban  

661
01:17:15,900 --> 01:17:22,800
geography. On this slide, you will see a snapshot 
from a descriptive analysis revealing disparities  

662
01:17:22,800 --> 01:17:27,960
in the burden of malnutrition across different 
racial and ethnic groups as identified by RDNs.  

663
01:17:28,680 --> 01:17:33,120
Additionally, the readmission rate for 
non-Hispanic Black individuals with  

664
01:17:33,120 --> 01:17:40,920
malnutrition was more than 26%, compared to less 
than 19% among non-Hispanic White individuals.  

665
01:17:41,700 --> 01:17:45,240
We were simply scratching the surface 
by these descriptive analysis. 

666
01:17:45,240 --> 01:17:49,260
I think there may be more opportunity to 
dig a little deeper in future research.  

667
01:17:52,680 --> 01:17:58,500
Malnutrition is a complex and burdensome condition 
that is often connected to social determinants of  

668
01:17:58,500 --> 01:18:04,500
health. Tracking hospital performance can 
lead to the detection of food insecurity.  

669
01:18:05,040 --> 01:18:10,020
We recently held a multi-stakeholder roundtable 
to discuss the connections between health equity,  

670
01:18:10,020 --> 01:18:16,680
hospital malnutrition care, and food insecurity. 
The participants' directive was to identify and  

671
01:18:16,680 --> 01:18:22,740
share solutions that could be readily implemented. 
Prior to the meeting, we interviewed national  

672
01:18:22,740 --> 01:18:27,780
experts to gather baseline information about 
factors that drive nutrition-related disparities,  

673
01:18:28,560 --> 01:18:34,380
existing barriers to addressing malnutrition, and 
potential roles for hospitals in identifying and  

674
01:18:34,380 --> 01:18:38,760
treating food insecurity. This really set 
the stage for what we could do within the  

675
01:18:38,760 --> 01:18:44,400
MQii to advance health equity through quality 
measurement. We see this as the next frontier.  

676
01:18:46,740 --> 01:18:52,140
On this slide, we start to weave in 
opportunities to identify and engage  

677
01:18:52,140 --> 01:18:57,480
patients around food insecurity by anchoring 
it to the global malnutrition composite score. 

678
01:18:57,480 --> 01:19:00,240
While we believe that this is an ideal approach,  

679
01:19:00,240 --> 01:19:04,800
we think that it can also serve as 
a playground for future research.  

680
01:19:09,180 --> 01:19:15,660
With a growing number of food pantries co-located 
in hospitals and the rise of home delivery of  

681
01:19:15,660 --> 01:19:21,180
medically tailored meals post-discharge, perhaps 
we can take a closer, more rigorous look into the  

682
01:19:21,180 --> 01:19:26,880
effectiveness of these programs. Through the 
MQii, we've had the opportunity to work with  

683
01:19:26,880 --> 01:19:32,520
several hospitals who have identified malnourished 
patients and have implemented small, short-term,  

684
01:19:32,520 --> 01:19:38,160
innovative nutrition interventions post-discharge. 
That said, there is a call for additional  

685
01:19:38,160 --> 01:19:43,140
studies that could be tackled to increase our 
evidence base. From generating evidence around  

686
01:19:43,140 --> 01:19:49,560
ROI to comparing efficacy of different nutrition 
interventions. There is a lot of work left to do.  

687
01:19:55,020 --> 01:19:59,820
I hope that this presentation has provided 
ample fodder for thought. I think that nutrition  

688
01:19:59,820 --> 01:20:04,260
field is well-positioned to tackle health 
equity through generating meaningful data,  

689
01:20:04,260 --> 01:20:09,420
building strong partnerships, and disseminating 
the findings so that learnings can be replicated. 

690
01:20:10,200 --> 01:20:13,860
Such research can be anchored in 
the acute care setting. Thank you  

691
01:20:13,860 --> 01:20:17,820
again for the opportunity to share a bit 
about the MQii. It is indeed a national  

692
01:20:17,820 --> 01:20:22,200
treasure and perhaps a good starting place 
to kick off some of this future research.

693
01:20:22,200 --> 01:20:30,000
DR. KIRK KERR: Hi. My name's Kirk Kerr. I'm a senior 
manager of Global Health Economics and Outcomes  

694
01:20:30,000 --> 01:20:36,660
Research at Abbott Nutrition. And I'd like to talk 
to you today about the economics of nutrition in  

695
01:20:36,660 --> 01:20:42,480
health care. By way of disclosures, I'll note 
that I am an employee and stockholder of Abbott  

696
01:20:42,480 --> 01:20:48,540
and that this presentation is not intended for 
continuing medical education purposes or credit.  

697
01:20:52,320 --> 01:20:57,600
Health economics and outcomes research 
is all about demonstrating the value of  

698
01:20:57,600 --> 01:21:02,520
treatments and interventions to a variety 
of health care stakeholders, for example,  

699
01:21:02,520 --> 01:21:07,920
once a health care stakeholder is a health care 
administrator who has to make decisions about the  

700
01:21:07,920 --> 01:21:12,300
treatments, interventions, and protocols 
that will be used at their institution.  

701
01:21:13,680 --> 01:21:18,360
Health care payers and policymakers 
make decisions about what treatments,  

702
01:21:18,360 --> 01:21:25,380
interventions and interventions will be covered by 
their government program or their health insurance  

703
01:21:25,380 --> 01:21:30,600
policy, and how much they're willing to pay for 
those health care treatments or interventions.  

704
01:21:31,260 --> 01:21:36,360
Health care providers make decisions about 
what interventions...and treatments will  

705
01:21:36,360 --> 01:21:43,980
best return their patients to optimal health.
And patients balance the need to improve their  

706
01:21:43,980 --> 01:21:50,640
health with the costs that they will bear to cover 
the cost of treatment—health care treatment.  

707
01:21:53,160 --> 01:22:00,540
Health economics and outcomes research combines 
our understanding of the clinical outcomes of  

708
01:22:00,540 --> 01:22:06,120
treatments and interventions with health economics 
to answer whether the outcome that we're getting  

709
01:22:06,120 --> 01:22:12,000
from a treatment or intervention is worth 
the spend on that treatment or intervention.  

710
01:22:13,380 --> 01:22:20,100
In the case of nutrition care, one asks; How much 
are we spending on nutrition or malnutrition?  

711
01:22:20,100 --> 01:22:28,846
And the answer is quite a lot. So, a study in 2014 
found that the burden—economic burden of disease- 

712
01:22:28,846 --> 01:22:37,260
associated malnutrition was $157 billion a year. 
Much of this burden was borne by the elderly,  

713
01:22:37,260 --> 01:22:44,880
65 and older population. This burden was 
calculated to be over $50 billion per year.  

714
01:22:46,620 --> 01:22:52,260
A subsequent study found that the economic 
burden of malnutrition was felt in all 50  

715
01:22:52,260 --> 01:22:57,720
states and the District of Columbia. And while it 
varied across those states from as low as about  

716
01:22:57,720 --> 01:23:07,020
$40 in one state to as high as $60 per capita 
in the District of Columbia, it was present  

717
01:23:07,020 --> 01:23:14,520
and felt and was significant in each state.
Again, the burden fell most heavily upon the 65  

718
01:23:14,520 --> 01:23:22,380
and older population, with the burden ranging from 
$80 per person to over $120 per person per year.  

719
01:23:25,860 --> 01:23:28,680
So what can be done to reduce this burden?  

720
01:23:31,020 --> 01:23:36,900
One intervention that has been found has been 
nutrition-focused quality improvement initiatives,  

721
01:23:36,900 --> 01:23:42,900
and these have been shown to be effective 
at improving patient care and have several  

722
01:23:46,140 --> 01:23:54,240
aspects in common or components in common,
typically. The first component is to identify  

723
01:23:54,240 --> 01:23:59,580
those patients who are at nutrition risk 
using a validated nutrition screening tool.  

724
01:24:01,020 --> 01:24:05,340
Of those patients who are identified 
to be at nutrition risk, a dietician  

725
01:24:07,320 --> 01:24:12,360
should meet with them to conduct a 
individualized nutrition assessment  

726
01:24:12,360 --> 01:24:21,960
to understand the nutrition needs of the 
patient. The patient's physician should also  

727
01:24:21,960 --> 01:24:28,080
meet with the patient to make an appropriate 
diagnosis of malnutrition when appropriate.  

728
01:24:29,820 --> 01:24:36,540
The physician, dietician, and the patient's entire 
care team plan should work together to develop a  

729
01:24:36,540 --> 01:24:43,680
nutrition care plan to provide education to the 
patient on proper nutrition and how nutrition  

730
01:24:43,680 --> 01:24:48,480
is important to health and improving and 
achieving the patient's optimal health. 

731
01:24:50,340 --> 01:24:58,500
Implementation of these measures at an acute care 
hospital was shown to be able to be improved over  

732
01:24:58,500 --> 01:25:05,040
a 4-month period. A hospital implemented a 
screening, nutrition assessment diagnosis, and  

733
01:25:05,040 --> 01:25:10,200
development of a nutrition care plan and 
was able to improve in all four of these  

734
01:25:10,200 --> 01:25:18,540
quality improvement areas. But what about the 
patients? What is the impact on the patient? Well,  

735
01:25:18,540 --> 01:25:23,520
a quality improvement initiative at 
Tampa General Hospital was implemented,  

736
01:25:23,520 --> 01:25:31,140
and this implementation included the automation 
of a dietician consult request to ensure that  

737
01:25:31,860 --> 01:25:35,580
dietician consults with at-risk 
patients happened in a timely manner.  

738
01:25:36,120 --> 01:25:41,340
Additionally, dietician recommendations were 
automatically inserted into the patient's care  

739
01:25:41,340 --> 01:25:47,100
plan to ensure that the nutrition care plan was 
developed and implemented in a timely fashion.  

740
01:25:48,420 --> 01:25:54,540
Additionally, patients with certain diagnoses 
were provided immunonutrition to improve their  

741
01:25:54,540 --> 01:25:59,820
overall nutrition status. This quality 
improvement initiative was found to reduce  

742
01:26:01,200 --> 01:26:07,920
infection rates in patients by 35% and 
also reduce hospital length of stay by 25%. 

743
01:26:08,460 --> 01:26:14,100
And both of these improvements were achieved 
without an increase in readmission rates.  

744
01:26:18,420 --> 01:26:24,180
Another quality improvement initiative 
was implemented at Advocate Health Care  

745
01:26:24,180 --> 01:26:30,660
in Illinois. This initiative included 
nutrition screening for all patients,  

746
01:26:30,660 --> 01:26:34,800
education and training of clinical 
staff on appropriate nutrition care,  

747
01:26:36,300 --> 01:26:42,120
provision of oral nutrition supplements as part 
of a nutrition care plan for at-risk patients,  

748
01:26:42,840 --> 01:26:49,020
and patient education on proper nutrition 
and how to improve their nutrition status.  

749
01:26:50,400 --> 01:26:57,540
This quality improvement program was found to 
reduce hospital length of stay by 25% and hospital  

750
01:26:57,540 --> 01:27:05,340
readmissions by 29%. And these improvements 
led to a savings of $3,800 per patient.  

751
01:27:08,040 --> 01:27:14,160
Additional quality improvement initiatives 
in other settings of care have found similar  

752
01:27:14,160 --> 01:27:20,640
improvements. An initiative in home health 
care focusing on screening of patients,  

753
01:27:20,640 --> 01:27:26,700
education of those who are at risk, and 
providing oral nutrition supplements to improve  

754
01:27:26,700 --> 01:27:34,800
nutrition status resulted in an 18% reduction in 
hospitalizations and savings of $1,500 per patient. 

755
01:27:35,520 --> 01:27:41,880
In an outpatient setting, a similar program of 
malnutrition screening, patient education, and  

756
01:27:42,420 --> 01:27:47,460
nutrition recommendations led to an 
11% reduction in overall health care  

757
01:27:47,460 --> 01:27:54,540
resource utilization and 
savings of $485 per patient.  

758
01:27:57,660 --> 01:28:04,440
In conclusion, I'll note that we've seen that 
malnutrition creates a significant economic  

759
01:28:04,440 --> 01:28:09,060
burden on the U.S. health care system, but that 
this burden can be addressed through quality  

760
01:28:09,060 --> 01:28:14,760
improvement initiatives that identify and treat 
patients at nutritional risk. We've seen that  

761
01:28:14,760 --> 01:28:20,940
these quality improvement initiatives can improve 
patient outcomes and reduce health care costs  

762
01:28:20,940 --> 01:28:24,480
and that these improvements are possible 
across a number of settings of care.

763
01:28:25,280 --> 01:28:31,860
I'll direct listeners to 
malnutritionquality.org to find toolkits  

764
01:28:31,860 --> 01:28:37,980
for implementing nutrition-focused quality 
improvement initiatives at their own institutions,  

765
01:28:37,980 --> 01:28:42,660
as well as measures to improve documentation 
and reimbursement of nutrition care.  

766
01:28:45,480 --> 01:28:52,500
For future research, I would encourage researchers 
to look at specific populations, such as patients  

767
01:28:52,500 --> 01:28:59,520
with diabetes or at risk for diabetes. Look 
at the...one could look at the impact of  

768
01:28:59,520 --> 01:29:06,720
the National Diabetes Prevention Program. Look at 
other ways that nutrition and nutrition programs  

769
01:29:06,720 --> 01:29:14,820
can assist patients with diabetes. Another 
population of interest might be oncology to  

770
01:29:14,820 --> 01:29:19,560
understand how nutrition interventions can 
improve continuity of treatment of these  

771
01:29:19,560 --> 01:29:25,320
patients or improve their overall outcomes. 
Additionally, as value-based payments,  

772
01:29:25,320 --> 01:29:30,060
initiatives and programs are gaining in 
popularity, it's important that these be  

773
01:29:30,060 --> 01:29:36,720
studied to understand their impact on patient 
care and patient outcomes. Thank you very much.  

774
01:29:36,720 --> 01:29:47,017
(BACKGROUND CONVERSATION)

775
01:29:47,017 --> 01:29:56,280
DR. KELLY TAPPENDEN: Okay. Thank 
you to each of our presenters for this excellent (INAUDIBLE) I would like to go ahead 
and start our question-and-answer session. 

776
01:29:56,280 --> 01:30:03,000
We have a nice chunk of time allotted here, so 
please do go to the question and answer tab on  

777
01:30:03,000 --> 01:30:12,420
your system and input some questions so that we 
can make sure that your interests are represented.  

778
01:30:13,980 --> 01:30:19,200
To start with, we have had a few people ask 
about where they can access the presentations.  

779
01:30:19,920 --> 01:30:27,480
And so if you go back out to the platform lobby, 
there is a tab for resources which has links and  

780
01:30:27,480 --> 01:30:32,100
documents for the session. The other thing 
I want you to know is that you can go ahead  

781
01:30:32,100 --> 01:30:39,660
and stream the presentations once again and 
look at those for a year following the session  

782
01:30:40,500 --> 01:30:46,560
by accessing this platform. So, just go ahead and 
do that and you can get this content all again.  

783
01:30:47,100 --> 01:30:54,180
So, welcome to our speakers. Thank you for joining 
us today. I would like to, I think, start at the  

784
01:30:54,180 --> 01:31:01,800
beginning and just talk about our definition of 
malnutrition. So, Dr. Jensen, I believe you're  

785
01:31:01,800 --> 01:31:09,600
here with us via telephone. We can't see you, 
but I understand you're here, and I am wondering  

786
01:31:09,600 --> 01:31:16,500
if you can just spend a couple of minutes 
talking about the definition of malnutrition. 

787
01:31:16,500 --> 01:31:22,740
You went through that as it relates to 
disease-related malnutrition and inflammation.  

788
01:31:22,740 --> 01:31:29,160
This is a really helpful construct for us in 
the context of malnutrition within U.S. hospitals.  

789
01:31:29,820 --> 01:31:35,940
But I've always found it a little bit confusing 
when we look at this as it's stratified with  

790
01:31:35,940 --> 01:31:41,940
sarcopenia. So, you shared that the definition 
for disease-related malnutrition includes loss  

791
01:31:41,940 --> 01:31:47,400
of lean tissue and functional capacity. We know 
that that's one of the attributes that we look  

792
01:31:48,000 --> 01:31:54,240
for the diagnosis. But yet, if I look at the ASPEN 
definition and several papers in the literature,  

793
01:31:54,240 --> 01:32:05,520
they seem to stratify them separately where we 
have malnutrition with or without sarcopenia. Yet  

794
01:32:05,520 --> 01:32:14,160
it seems to me that so very often and sarcopenia, 
by virtue of looking at muscle mass and functional  

795
01:32:14,160 --> 01:32:21,000
capacity, is incorporated into the definition of 
malnutrition. Is there really a meaningful absence  

796
01:32:21,000 --> 01:32:29,400
of malnutrition in individuals who are diagnosed 
with sarcopenia? Have studies been done to see  

797
01:32:29,400 --> 01:32:35,700
if we can really find major populations 
that are sarcopenic yet well-nourished?

798
01:32:37,040 --> 01:32:45,480
DR. GORDON JENSEN: Thank you very much for 
the insightful question. I view sarcopenia  

799
01:32:45,480 --> 01:32:53,460
and also cachexia as malnutrition overlapped 
syndromes, and I very much think that they  

800
01:32:54,840 --> 01:33:02,700
are not necessarily distinct types of 
malnutrition. They are in, you know,  

801
01:33:02,700 --> 01:33:08,640
well-described settings in terms of, you know, 
what sarcopenia looks like, what cachexia looks  

802
01:33:08,640 --> 01:33:15,720
like. They both can have intimate ties to 
disease-related malnutrition as well. But  

803
01:33:15,720 --> 01:33:22,020
the malnourished state in these overlap syndromes 
is in fact consistent with the malnutrition that  

804
01:33:22,020 --> 01:33:29,580
we've been describing in hospital settings quite 
often. And, you know, we're making attempts to  

805
01:33:29,580 --> 01:33:39,480
work very closely with the cachexia and sarcopenia 
groups to arrive at a broader consensus. There's  

806
01:33:39,480 --> 01:33:45,840
days I think we're close; there's days 
I think we're further apart. But I think  

807
01:33:45,840 --> 01:33:54,480
the key take-home message for both sarcopenia, 
and cachexia as well, is these people are often  

808
01:33:54,480 --> 01:34:01,080
malnourished. And associating with those conditions, 
there's very good research data that show  

809
01:34:01,080 --> 01:34:09,300
that malnutrition is often part of sarcopenia.
Of course, it quite often is of cachexia as well.  

810
01:34:09,300 --> 01:34:14,820
But the important take-home message for all should 
be to recognize that those overlapped syndromes,  

811
01:34:14,820 --> 01:34:19,800
these people are malnourished. It's important to 
recognize that, and it's important to intervene  

812
01:34:19,800 --> 01:34:23,400
as appropriate. So, that's a succinct 
answer, but thanks for a great question.

813
01:34:23,400 --> 01:34:30,000
DR. KELLY TAPPENDEN: Well, thank you. We have a question from 
the audience asking you, Dr. Jensen, to comment on  

814
01:34:30,000 --> 01:34:35,580
the association of inflammation—inflammation, 
and presence of malnutrition and difficulties  

815
01:34:35,580 --> 01:34:42,720
correcting malnutrition. This person's concern 
is that as strong as this association might be,  

816
01:34:42,720 --> 01:34:47,460
we do not understand the mechanisms of this 
association, and it's not clear to them that  

817
01:34:47,460 --> 01:34:52,980
there is a direct, causative relationship, at 
least in any individual, and not so clear that  

818
01:34:52,980 --> 01:34:58,380
anti-inflammatory approaches do help in cancer 
cachexia, which is their field of practice.

819
01:35:01,200 --> 01:35:08,040
DR. GORDON JENSEN: The first observation I would 
make is that in very severe inflammatory states,  

820
01:35:08,040 --> 01:35:14,520
it's very difficult to make a favorable 
impact with nutrition and certainly with  

821
01:35:14,520 --> 01:35:23,100
nutrition interventions alone, which I would not 
recommend at all because it is imperative to treat  

822
01:35:23,100 --> 01:35:29,040
both the underlying disease and inflammatory 
process as well as the malnutrition. Now,  

823
01:35:29,040 --> 01:35:36,420
I'm not for a moment suggesting that that means 
one should withhold malnutrition—withhold  

824
01:35:36,420 --> 01:35:43,020
nutrition intervention in these settings because 
it's fundamentally important in helping people  

825
01:35:43,020 --> 01:35:50,280
get through potential treatment interventions. 
Medical treatment interventions are fundamentally  

826
01:35:51,300 --> 01:35:58,680
important in terms of perhaps blunting further 
deterioration to some degree. But fundamentally,  

827
01:35:58,680 --> 01:36:04,620
the premise is correct that you have to address 
the underlying disease and inflammatory process.  

828
01:36:04,620 --> 01:36:10,800
And of course, there's lots of very interesting 
research looking at potential interventions,  

829
01:36:10,800 --> 01:36:17,220
you know, whether it's omega-3 fatty acids, 
whether it's probiotics, whether it's improved  

830
01:36:17,220 --> 01:36:22,740
glycemic control—a host of opportunities here.
And, you know, part of it is going to be  

831
01:36:22,740 --> 01:36:31,140
recognizing people in these states early, tailing 
in our interventions to specific disease states,  

832
01:36:31,140 --> 01:36:35,400
specific types of inflammation. And of 
course, these are outstanding research  

833
01:36:35,400 --> 01:36:41,640
themes to be further explored. I think the 
key understanding here is why it's important  

834
01:36:41,640 --> 01:36:48,900
to understand the contributions or underlying 
disease on inflammatory response is it impacts  

835
01:36:48,900 --> 01:36:54,180
upon our assessment, it impacts upon the types 
of interventions that we would bring to bear,  

836
01:36:54,180 --> 01:37:00,660
and it also impacts upon the outcomes that we 
could expect and share with clinicians and share  

837
01:37:00,660 --> 01:37:05,749
with patients and their families. So, I think 
I'll wrap that up before I take up all the Q&A.

838
01:37:05,749 --> 01:37:11,280
DR. KELLY TAPPENDEN: I have just one more question, 
though, on this topic. There's...  

839
01:37:11,280 --> 01:37:14,700
is there anticipated future 
development in assessing for  

840
01:37:14,700 --> 01:37:20,040
sarcopenia with CT scan evaluation? 
This is a question from a dietitian.

841
01:37:20,040 --> 01:37:27,960
DR. GORDON JENSEN: Yeah. I think the body imaging 
techniques for body composition are sort of,  

842
01:37:27,960 --> 01:37:35,460
you know, the current state of the art if you 
will, and CT scan and to look at muscle mass  

843
01:37:35,460 --> 01:37:41,700
can certainly be used to look at sarcopenia. 
You know, the challenge has been and, you know,  

844
01:37:41,700 --> 01:37:48,600
Vickie Baracos, has done a wonderful job with 
this, is, you know, it's hard to get someone  

845
01:37:48,600 --> 01:37:54,300
to do a CT just to look at body composition. 
But you can take advantage of those that are  

846
01:37:54,300 --> 01:37:58,980
being done for clinical purposes. So, you know, 
it wouldn't be all that unusual for someone with  

847
01:37:58,980 --> 01:38:04,860
sarcopenia to also be getting an abdominal CT 
to look for some underlying disease or what  

848
01:38:04,860 --> 01:38:12,600
have you—certainly very common in cancer, for 
example. And with the appropriate CT imaging,  

849
01:38:12,600 --> 01:38:20,840
you can take advantage of that and the appropriate 
analysis and use CT to get, you know, muscle mass.

850
01:38:20,840 --> 01:38:25,980
DR. KELLY TAPPENDEN: Thank you. I want to open this 
up to several of our other speakers now.  

851
01:38:26,820 --> 01:38:32,580
When CMS is auditing hospitals and assessing 
if institutions have been over-reimbursed for  

852
01:38:32,580 --> 01:38:39,720
malnutrition diagnosis, what are they using 
as assessment criteria? Dr. Guenter,  

853
01:38:39,720 --> 01:38:44,145
perhaps I could ask you this.

854
01:38:44,145 --> 01:38:50,160
DR. PEGGI GUENTER: Yes. So, what I was going to 
say is there will be a full discussion later by  

855
01:38:51,240 --> 01:38:55,680
Marsha Schofield on inpatient reimbursement, 
and I think she'll cover this nicely.  

856
01:38:56,760 --> 01:39:05,700
Meetings that we have had in the past with CMS, 
there is not a universal malnutrition diagnostic  

857
01:39:05,700 --> 01:39:13,500
indicators and characteristics that they're using, 
and it's a bit difficult to understand what the  

858
01:39:13,500 --> 01:39:18,420
criteria they're using are. So, I think, but 
I think that's moved along a little bit more,  

859
01:39:20,040 --> 01:39:25,460
hopefully in discussions with CMS, and 
I think Marsha will cover that nicely.

860
01:39:25,460 --> 01:39:30,600
DR. KELLY TAPPENDEN: So, Kristi, on that topic, what do you  

861
01:39:30,600 --> 01:39:35,820
recommend then as part of the quality 
initiative when it comes to coding?

862
01:39:36,560 --> 01:39:38,640
DR. KRISTI MITCHELL: So, I mean...

863
01:39:38,640 --> 01:39:41,520
DR. KELLY TAPPENDEN: I know it's not one of 
the four things, but, you know.

864
01:39:41,520 --> 01:39:47,460
DR. KRISTI MITCHELL: Yeah. So, I just want to just point out 
that in our work with the Malnutrition Quality  

865
01:39:47,460 --> 01:39:52,200
Improvement Initiative, we're not focusing 
on coding as much as we're focused in on  

866
01:39:52,200 --> 01:39:58,860
the important steps around the malnutrition 
care process. So, as much as I would love  

867
01:39:58,860 --> 01:40:04,520
to answer that question about coding, I don't 
think I'm well positioned to do so. Thank you.

868
01:40:04,520 --> 01:40:10,500
DR. KELLY TAPPENDEN: So, does anyone else want to comment on 
that to me? Because it strikes me that although  

869
01:40:10,500 --> 01:40:15,240
as we nutritionists are very motivated to 
do that, part of the value to the hospital  

870
01:40:15,240 --> 01:40:21,540
is in fact being able to code and get that 
value-added reimbursement, right? Dr. Kerr.

871
01:40:21,540 --> 01:40:34,020
DR. KIRK KERR: Yeah. I agree the...a big part of the value 
of the...that's trying to be demonstrated by  

872
01:40:34,020 --> 01:40:39,900
initiatives like the ASPEN Value Project and the 
Malnutrition Quality Improvement Initiative is  

873
01:40:39,900 --> 01:40:48,420
to show that malnutrition is an ongoing challenge 
in hospitals and that properly coding for those will  

874
01:40:48,420 --> 01:40:56,220
allow the hospital to get reimbursed for that and 
to receive the value that of the work that they're  

875
01:40:56,220 --> 01:41:03,900
doing because they are doing...patients who are 
malnourished have more co-morbidities, they're  

876
01:41:03,900 --> 01:41:09,180
sicker, and they need more care, and the hospitals 
need to be reimbursed appropriately for providing  

877
01:41:09,180 --> 01:41:14,460
that care. And anything that can be done to 
make sure that those hospitals are appropriately  

878
01:41:14,460 --> 01:41:20,640
reimbursed, or those institutions, not just limited 
to hospitals, but any institution that's providing  

879
01:41:21,600 --> 01:41:25,800
that care for malnourished patients, 
they need to be reimbursed appropriately.

880
01:41:25,800 --> 01:41:31,800
DR. PEGGI GUENTER: Peggi. This is Peggi Guenter again. 
I just want to make another comment on that.  

881
01:41:32,640 --> 01:41:38,880
We have shown several times over the years using 
HCUP data that we know that malnutrition  

882
01:41:38,880 --> 01:41:44,760
diagnoses are probably not being coded as often 
as they should. The latest study we have from  

883
01:41:44,760 --> 01:41:53,700
2018 is a rate of malnutrition at 8.9%. And 
we know from individual studies that it goes  

884
01:41:53,700 --> 01:42:01,620
up in an individual reviews in institutions 
or in small studies, that it goes up to 30,  

885
01:42:01,620 --> 01:42:08,640
even up to 50% in really high-risk patients. 
So, we know there's a disconnect between what's  

886
01:42:08,640 --> 01:42:14,640
being diagnosed, what's being assessed, what's 
being diagnosed, and then what's being coded.  

887
01:42:14,640 --> 01:42:22,800
And that's another step beyond even the global 
composite measure. But I think it will lead  

888
01:42:22,800 --> 01:42:28,140
to better coding if...once these measures are 
implemented in an inpatient reporting system.

889
01:42:29,760 --> 01:42:31,620
DR. KELLY TAPPENDEN: Dr. Guenter, actually I sure hope so.  

890
01:42:32,400 --> 01:42:39,600
That first 2010 paper and then 2018, I cite that 
all the time because it just underscores the  

891
01:42:39,600 --> 01:42:44,040
problem that we have. I'm very grateful for the 
Quality Initiative and making sure that we're  

892
01:42:44,040 --> 01:42:48,780
going through that process, but how sure can 
we be until that process is completed, right?  

893
01:42:48,780 --> 01:42:52,380
And I think that those data are really 
reflective of that. Alright. Dr. Winkler.

894
01:42:52,380 --> 01:43:00,060
DR. MARION WINKLER: I just wanted to add a couple of just 
real-life clinical scenarios. I've done a number  

895
01:43:00,060 --> 01:43:06,360
of appeals on behalf of or helped on behalf of 
the hospital and our clinical documentation people  

896
01:43:07,620 --> 01:43:15,780
when a malnutrition diagnosis was questioned 
or not reimbursed. And some of the discrepancy  

897
01:43:15,780 --> 01:43:22,140
historically has been the reliance on serum 
albumin level as triggering it. And with the  

898
01:43:22,140 --> 01:43:28,860
shift in the AND and ASPEN the criteria and 
implementation of that over the last really decade  

899
01:43:28,860 --> 01:43:38,460
now as we begin to do our documentation according 
to that or the appeal according to that and the  

900
01:43:38,460 --> 01:43:43,740
process we use, there's a discrepancy there. Now, 
it seems to be shifting. There are a number of,  

901
01:43:45,720 --> 01:43:50,160
I guess, auditing companies that 
help hospitals prepare for this. So,  

902
01:43:50,160 --> 01:43:58,080
I'm seeing much more triggers based on the AND 
and ASPEN criteria. So, that's a good thing.  

903
01:43:58,080 --> 01:44:05,700
What is also happening, though, is that there's 
benchmarking against institutions with larger,  

904
01:44:05,700 --> 01:44:10,440
similar-sized institutions. And one 
of the things that's really been  

905
01:44:13,500 --> 01:44:18,540
bothering me, I guess is a good term, and 
I hope we'll have some discussion during  

906
01:44:18,540 --> 01:44:26,580
this whole conference is when we look at the 
number or percentage of malnutrition documented  

907
01:44:26,580 --> 01:44:34,080
or coded for and our levels are lower, that 
there's actually a push to increase that. 

908
01:44:34,080 --> 01:44:40,500
And so I want to have some conversation at some 
point on how do you use the benchmarking. Because  

909
01:44:40,500 --> 01:44:48,240
my interpretation is if we know we are documenting 
it and treating for it, then it's better to have  

910
01:44:48,240 --> 01:44:55,320
a lower percent of malnutrition in our patient 
population that that's actually a good thing.

911
01:44:56,840 --> 01:45:00,180
DR. KELLY TAPPENDEN: Okay. Very good. We're going to talk about  

912
01:45:00,180 --> 01:45:04,680
this issue more in the session after our 
break. So, right now there's a question  

913
01:45:05,400 --> 01:45:10,440
for Dr. Kerr on the how the financial savings 
were calculated in your presentation.

914
01:45:11,360 --> 01:45:17,400
DR. KIRK KERR: Sure, so the financial savings are 
calculated by comparison of patients who were  

915
01:45:17,400 --> 01:45:24,570
seen in the hospital after the Quality Improvement 
Initiative was initiated and what their health  

916
01:45:24,570 --> 01:45:29,820
care costs were and comparing those to patients 
who were seen before the Improvement Initiative  

917
01:45:29,820 --> 01:45:36,420
was initiated. And so, it's an average of the 
health care costs of those two different groups,  

918
01:45:36,420 --> 01:45:41,000
an average of the difference of the health care 
costs between those two groups of patients.

919
01:45:41,000 --> 01:45:47,160
DR. KELLY TAPPENDEN: And then in follow-up to that, 
Dr. Kerr, how can therapy, such as  

920
01:45:47,700 --> 01:45:54,000
OT or speech, be best utilized to increase 
outcomes in the field and patients with  

921
01:45:54,000 --> 01:45:58,560
respect to nutrition and malnutrition, 
specifically in the outpatient and home  

922
01:45:58,560 --> 01:46:03,360
health settings? How can we collaborate with 
these other allied health professionals?

923
01:46:05,280 --> 01:46:09,360
DR. KIRK KERR: I think those are great questions. I 
think that there needs to be that collaboration  

924
01:46:09,360 --> 01:46:17,160
and an integration of care with those groups to 
ensure that the patients are receiving the best  

925
01:46:17,160 --> 01:46:24,300
care possible. The studies in particular that 
we looked at that I mentioned looked at patients  

926
01:46:24,300 --> 01:46:30,960
who were receiving a standard of care plus 
something related to nutrition...a nutrition  

927
01:46:30,960 --> 01:46:39,060
screening and the nutrition recommendation. 
So, I can't speak specifically to how those  

928
01:46:39,060 --> 01:46:45,180
were integrated other than they were part 
of the existing standard of care. What  

929
01:46:45,180 --> 01:46:49,760
patients received was whatever was part of the 
existing standard of care in those institutions.

930
01:46:49,760 --> 01:46:56,280
DR. KELLY TAPPENDEN: It's a really good point, Dr. Guenter, I 
don't know if you're familiar with any literature,  

931
01:46:56,280 --> 01:47:02,160
but is there good evidence looking 
at involving a variety of specialties  

932
01:47:02,160 --> 01:47:06,240
in malnutrition care? Do we have 
evidence to show that that helps?  

933
01:47:07,140 --> 01:47:14,160
As presumably it wouldn't in many situations, right, but are we utilizing our colleagues enough?

934
01:47:14,840 --> 01:47:22,020
DR. PEGGI GUENTER: I think we probably are not. But 
I don't know that...there certainly doesn't seem to  

935
01:47:22,020 --> 01:47:30,420
be any cost data and value data that I know of. 
But I think it's certainly something that...as we  

936
01:47:30,420 --> 01:47:40,560
move along with a standardized tool to do these 
steps and we start really beginning to correctly  

937
01:47:40,560 --> 01:47:47,340
look at quality measures and get a baseline of 
what we actually have in terms of malnutrition,  

938
01:47:47,340 --> 01:47:53,880
I think that the biggest problem is, you know, 
we don't know what we're looking at. And Marion,  

939
01:47:53,880 --> 01:48:00,360
I think, probably sees all the patients in her 
hospital and knows...is very comfortable that  

940
01:48:00,360 --> 01:48:05,580
her rate is lower. But when I 
look at 8.9% on a national basis,  

941
01:48:05,580 --> 01:48:12,240
somehow I think that we've missed people because 
then we look at studies that have 30 or 50%. So,  

942
01:48:12,240 --> 01:48:16,320
I think we've got to get together with 
all of these efforts we're doing with  

943
01:48:17,040 --> 01:48:22,680
validation of its tool, with putting in quality 
measures, I think we'll get to our baseline  

944
01:48:22,680 --> 01:48:28,200
and we'll know what we're dealing with, and then 
we can begin to look at care models that would  

945
01:48:28,200 --> 01:48:36,000
include things like OTPT and speech therapy.
We can look at specific interventions. We need  

946
01:48:36,000 --> 01:48:43,320
to study really homogeneous populations. We can't 
say all hospitalized patients, we can't say all  

947
01:48:43,320 --> 01:48:50,280
cancer patients. We have to look specifically when 
we're doing intervention studies and randomized  

948
01:48:50,280 --> 01:48:58,380
prospective studies that were looking at a 
specific population because nutrition, you know,  

949
01:48:58,380 --> 01:49:02,820
needs and nutrition outcomes are going to be 
very different for each of these populations.

950
01:49:02,820 --> 01:49:11,700
DR. KELLY TAPPENDEN: Yeah, we've got so much work to do. 
So, from Rebecca and Tomason, is GLIM and/or  

951
01:49:11,700 --> 01:49:16,860
ASPEN preferred for insurance reimbursement? 
We have had a few rejections from Blue Cross  

952
01:49:16,860 --> 01:49:20,640
Blue Shield who won't take GLIM. Does 
anyone have any insight into that?

953
01:49:26,000 --> 01:49:31,680
DR. PEGGI GUENTER: This is Peggi Guenter I really think it 
would be best to wait until we hear from Marsha,  

954
01:49:32,640 --> 01:49:39,000
who's really a wonderful resource, Marsha 
Schofield from the Academy. She's got a lot  

955
01:49:39,000 --> 01:49:44,460
of good sense of this. I think Gordon may...also Dr. Jensen may also have some insight  

956
01:49:45,420 --> 01:49:51,240
on this as well. But I think just trying to wait 
a little bit on this discussion would be great.

957
01:49:51,240 --> 01:49:54,780
DR. KELLY TAPPENDEN: Yeah, let's do that. So, 
is anyone familiar with malnutrition  

958
01:49:54,780 --> 01:49:59,880
identified in cancer survivors? If so, what 
are possible screening tools, causes, treatment  

959
01:49:59,880 --> 01:50:05,100
interventions? Can treatment of malnutrition 
and inflammation with diet or probiotics  

960
01:50:05,760 --> 01:50:10,200
decrease cardiovascular disease risk 
and outcome? So, we've got a broad  

961
01:50:10,200 --> 01:50:18,120
range of questions there regarding cancer and 
CVD-specific identification of malnutrition.  

962
01:50:24,120 --> 01:50:29,820
I think this really does underscore the need 
we heard several times for us to have handles  

963
01:50:29,820 --> 01:50:35,640
on specific populations and diagnoses. And, 
you know, we've got such broad data across a  

964
01:50:35,640 --> 01:50:42,780
number of patients, but we need to understand 
specific diagnoses and stratify patients more.  

965
01:50:42,780 --> 01:50:44,937
We have another— 

966
01:50:44,937 --> 01:50:45,437
DR. GORDON JENSEN: I have— 

967
01:50:45,437 --> 01:50:47,435
DR. KELLY TAPPENDEN: Please. 

968
01:50:47,435 --> 01:50:51,091
DR. GORDON JENSEN: I can go ahead and make a quick comment on that if you'd like. It's Gordon.  

969
01:50:51,091 --> 01:51:00,180
I think it is imperative as you just said, as 
Peggi just said, that when we start talking about  

970
01:51:00,180 --> 01:51:09,660
testing interventions for populations or diseases, 
it needs to be very specific, well-characterized  

971
01:51:09,660 --> 01:51:14,580
subgroups. And, of course, if you talk about 
it in the context of research priorities,  

972
01:51:14,580 --> 01:51:21,120
I had highlighted in my presentation that among 
the first that really warrant that kind of,  

973
01:51:21,120 --> 01:51:27,480
you know, the significant randomized controlled 
trials will be those where we think there are most  

974
01:51:27,480 --> 01:51:34,500
likely fundamental opportunities for success, 
where we have a high likelihood of validating  

975
01:51:34,500 --> 01:51:40,380
the successful outcomes associated with our 
intervention. So, I would just emphasize,  

976
01:51:40,380 --> 01:51:46,400
as you said, that I think that that is imperative 
as we think about future research priorities.

977
01:51:46,400 --> 01:51:51,360
DR. KELLY TAPPENDEN: Thank you. We have a question from Carol Jennings from AdventHealth, who  

978
01:51:51,360 --> 01:51:56,820
is very interested in the clinical sequelae 
of malnutrition in the near term, for example.  

979
01:51:56,820 --> 01:52:03,000
What is the timeframe where we would see clinical 
manifestations of muscle loss and vitamin deficits  

980
01:52:03,000 --> 01:52:09,480
within a week or two? Our references all reflect 
longer-term timelines, and when speaking with the  

981
01:52:09,480 --> 01:52:15,720
physicians, it's hard not to sell...to convince 
them that malnutrition impacts their very thin  

982
01:52:15,720 --> 01:52:21,300
patients, but for those that are overweight or 
normal weight, they are slower to recommend,  

983
01:52:21,300 --> 01:52:27,900
accept the recommendations for nutrition. What 
strategies would any of you recommend to Carol?

984
01:52:32,520 --> 01:52:37,740
DR. GORDON JENSEN: Well, this is Gordon again. That's 
a very good question and that data in my clinical  

985
01:52:37,740 --> 01:52:47,160
life I encountered virtually weekly. And in terms 
of what the timeline of malnutrition—in this case  

986
01:52:47,160 --> 01:52:55,020
undernutrition—is very much dependent on the 
severity...the setting, and the severity of the  

987
01:52:55,020 --> 01:53:02,820
insult, so, you know, acute critical illness, for 
example, you know, intensive care, trauma, burns,  

988
01:53:02,820 --> 01:53:08,460
all sorts of things. Those people can become 
profoundly undernourished very quickly—days,  

989
01:53:08,460 --> 01:53:15,360
week, or two. And of course, acutely you will see, 
you know, micronutrient changes, protein changes . 

990
01:53:16,620 --> 01:53:22,440
To demonstrate erosion of muscle mass can be very 
difficult in those kinds of settings. But again,  

991
01:53:22,440 --> 01:53:27,420
some of the imaging techniques that we're 
beginning to use could be quite helpful. 

992
01:53:27,420 --> 01:53:35,940
If that's just pure semi-starvation, the timeline 
certainly can be somewhat longer—weeks to months.  

993
01:53:35,940 --> 01:53:41,580
And of course, it's not until you're in the 
time, in the realm of 30% weight loss that  

994
01:53:41,580 --> 01:53:49,080
you're talking life-threatening malnutrition. 
So, the timeline can vary considerably. 

995
01:53:49,080 --> 01:53:54,360
I think the importance is to demonstrate to 
clinicians that are asking, you know, why do  

996
01:53:54,360 --> 01:54:00,780
you want to intervene upon my patient, that we 
can, you know, literally at the molecular level— 

997
01:54:00,780 --> 01:54:06,180
whether it's metabolic profile, whether it's 
micronutrients, whether it's proteins—we could  

998
01:54:06,180 --> 01:54:14,100
demonstrate fundamental changes in nutritional 
status and impact upon outcomes in an adverse way  

999
01:54:15,360 --> 01:54:22,020
relatively early in a clinical course. And of 
course, I appreciate that we you have a very large  

1000
01:54:22,020 --> 01:54:26,400
patient in a hospital bed, it's not obvious 
they're losing muscle, it's not obvious that  

1001
01:54:26,400 --> 01:54:31,080
they have micronutrient deficiencies. And of 
course, one of the priorities for the workshop  

1002
01:54:31,080 --> 01:54:37,260
is to talk about better ways we may be able to 
identify and demonstrate malnourished patients  

1003
01:54:37,260 --> 01:54:43,800
based on laboratory screening, based on 
metabolic profiling, based on risk. So,  

1004
01:54:43,800 --> 01:54:50,040
a lot of work to do, but it's very important. 
This, I think, is alluded to here to dialogue  

1005
01:54:50,040 --> 01:54:54,720
with clinicians about what we know, what we 
don't know. I mean, I think a very important,  

1006
01:54:54,720 --> 01:54:58,680
you know, very important thing is to 
also be upfront, which is we know 

1007
01:54:59,220 --> 01:55:06,900
we don't believe that albumin and in pre-albumin are very 
useful malnutrition indicators in the setting of  

1008
01:55:06,900 --> 01:55:09,960
disease and inflammation, for example.
But I'll stop there. Thanks.

1009
01:55:09,960 --> 01:55:15,660
DR. KELLY TAPPENDEN: Great answer. Thank you. I'm going to 
shift our focus for the last question of this  

1010
01:55:15,660 --> 01:55:21,420
session, and that is from one of our audience 
members: How can we control malnutrition in  

1011
01:55:21,420 --> 01:55:27,120
developing countries, specifically where there's 
no good concept of nutritionists and dietitians,  

1012
01:55:27,120 --> 01:55:32,580
and doctors mostly prescribe their patients 
with dietary guidelines? So, this makes me  

1013
01:55:32,580 --> 01:55:40,140
think of GLIM versus the AND/ASPEN criteria for 
malnutrition. Who would like to address that?  

1014
01:55:45,540 --> 01:55:52,140
International countries where there are not 
nutritionists and dieticians represented,  

1015
01:55:52,140 --> 01:55:56,640
and doctors are sort of left with just 
standard guidelines for their patients.

1016
01:55:56,640 --> 01:56:01,740
DR. GORDON JENSEN: Well, if no one wants, I'll 
be happy to quickly take that on, because,  

1017
01:56:01,740 --> 01:56:09,480
of course, this is one of the fundamental, 
you know, rationales that underpin GLIM,  

1018
01:56:09,480 --> 01:56:17,280
the Global Leadership Initiative on Malnutrition, 
where it was specifically designed to be used in  

1019
01:56:17,280 --> 01:56:23,280
settings where there weren't necessarily an 
abundance of clinical nutrition resources,  

1020
01:56:23,280 --> 01:56:32,400
skilled dieticians, certainly not body imaging for 
body composition, as well as other resources. And,  

1021
01:56:32,940 --> 01:56:38,220
you know, the vision with GLIM was they could be 
used much more widely. But I do want to be clear  

1022
01:56:38,220 --> 01:56:44,100
and people don't realize this, there's plenty of 
places in North America where these resources are  

1023
01:56:44,100 --> 01:56:52,560
also not readily available in terms of recognition 
of malnutrition and intervention and follow up.  

1024
01:56:52,560 --> 01:57:00,360
But on a global setting, the intent with GLIM 
is very much to have a simple, user-friendly  

1025
01:57:00,360 --> 01:57:08,520
approach that can be used in a great diversity 
of settings across the globe. And of course,  

1026
01:57:08,520 --> 01:57:12,960
you know, it's undergoing validation testing 
now. There's still a lot of work to do,  

1027
01:57:12,960 --> 01:57:19,680
you know. In terms of North America, you know, 
the vision there is that, in fact, if GLIM is  

1028
01:57:19,680 --> 01:57:27,600
used as the initial approach with screening and 
assessment, it generates a preliminary diagnosis  

1029
01:57:27,600 --> 01:57:32,940
of malnutrition that then should be confirmed 
by more comprehensive assessment by a skilled  

1030
01:57:32,940 --> 01:57:35,100
dietitian or other practitioner.
But...thank you.

1031
01:57:35,100 --> 01:57:43,140
DR. MARION WINKLER: It probably also speaks to 
the gap of the need to train practitioners  

1032
01:57:43,680 --> 01:57:47,480
across all disciplines, and 
that could be global as well.

1033
01:57:47,480 --> 01:57:55,440
DR. KELLY TAPPENDEN: Absolutely. Alright, with that, 
I want to thank each of our presenters for  

1034
01:57:55,440 --> 01:58:00,540
your excellent presentations and thoughtful 
insight into this. We will now take a quick  

1035
01:58:00,540 --> 01:58:06,600
break for the second part of our first session, 
which will begin at 2:15 PM Eastern. Thank you.

1036
01:58:06,600 --> 01:58:11,940
DR. KELLY TAPPENDEN: Welcome back. I'm pleased we'll 
be able to continue with session one now with  

1037
01:58:11,940 --> 01:58:16,320
presentations on Improving Assessment 
to Nutrition Care. I'm your moderator  

1038
01:58:16,320 --> 01:58:21,060
for today. My name is Kelly Tappenden from 
the University of Illinois at Chicago. Now,  

1039
01:58:21,060 --> 01:58:26,340
what we have planned is that Dr. Hand will begin 
the session with a presentation on the  

1040
01:58:26,340 --> 01:58:34,560
Optimal Number of Registered Dietitians Needed to Address Malnutrition-Related Issues. Then Marsha  

1041
01:58:34,560 --> 01:58:41,340
Schofield will discuss Inpatient Payment Issues. 
That will follow with Dr. Nepple presenting on  

1042
01:58:41,340 --> 01:58:47,760
Malnutrition Diagnosis During Adult Inpatient Hospitalizations. And our last presentation  

1043
01:58:47,760 --> 01:58:54,480
in the session will be by Dr. Grega on Lifestyle 
Medicine Reimbursement. Again, during the session,  

1044
01:58:54,480 --> 01:58:59,040
please do share your questions for 
the presenters in the chat box and  

1045
01:58:59,040 --> 01:59:02,580
then afterwards we'll get together 
and discuss it all. Thanks very much.

1046
01:59:02,580 --> 01:59:13,740
DR. ROSA HAND: Hello, and thank you so much to the organizers for 
inviting me to give this brief talk on the topic  

1047
01:59:13,740 --> 01:59:19,080
of Optimal Number of Registered Dietitians 
Needed to Address Nutrition-Related Issues.  

1048
01:59:21,720 --> 01:59:26,820
During these 10 minutes, I hope to describe 
the current knowledge of registered dietitian  

1049
01:59:26,820 --> 01:59:33,180
staffing in inpatient settings, describe research 
in progress related to staffing and malnutrition,  

1050
01:59:33,180 --> 01:59:39,660
and finally, to describe future research needs 
related to RDN staffing. So, I'm going to  

1051
01:59:39,660 --> 01:59:45,600
start by reviewing three existing studies on the 
topic of RDN staffing in the inpatient setting.  

1052
01:59:46,500 --> 01:59:53,040
The first study was published in 2015. In this 
study, we used a large sample from across the  

1053
01:59:53,040 --> 01:59:57,900
country to describe the time requirements 
for inpatient encounters based on facility,  

1054
01:59:57,900 --> 02:00:03,360
patient, and RDN characteristics, and 
then developed a model that would  

1055
02:00:03,360 --> 02:00:08,400
predict registered dietitian staffing needs 
that would be similar to other facilities.  

1056
02:00:10,800 --> 02:00:16,440
In this project, we had both adult and pediatric 
facilities participate, but I'm going to focus  

1057
02:00:16,440 --> 02:00:21,660
on the adult data for this presentation.
As you can see from the characteristics,  

1058
02:00:21,660 --> 02:00:26,520
we had 78 adult facilities participate 
and they contributed just over  

1059
02:00:27,420 --> 02:00:34,560
35,000 patient nutrition encounters. We had a 
nice spread of facility size and facility acuity.  

1060
02:00:36,840 --> 02:00:42,480
One of the first things that we were able to 
identify in this 2015 study was that the time  

1061
02:00:42,480 --> 02:00:48,660
needed for nutrition encounters increases as the 
registered dietitian-assessed patient complexity  

1062
02:00:48,660 --> 02:00:54,720
increased, which is logical and which was 
statistically significant by ANOVA. It is  

1063
02:00:54,720 --> 02:01:00,480
important to note that this slide has combined 
adult and pediatric time and complexity data.  

1064
02:01:02,700 --> 02:01:09,480
After the initial description of the encounters, 
we conducted a three-level regression model to  

1065
02:01:09,480 --> 02:01:14,280
account for clustering of the data and random 
variation among registered dietitians and  

1066
02:01:14,280 --> 02:01:20,880
facilities. And we were able to come up with the 
predictive model that you see on the screen that  

1067
02:01:20,880 --> 02:01:26,400
allows a clinical nutrition manager to determine 
the number of minutes of direct nutrition care  

1068
02:01:26,400 --> 02:01:32,160
time that they would need in their facility based 
on patient characteristics, including whether or  

1069
02:01:32,160 --> 02:01:37,560
not the patient is in the ICU, the number of 
patients who are high or moderate complexity,  

1070
02:01:37,560 --> 02:01:42,300
and the number of patients who need an 
initial assessment versus a reassessment. 

1071
02:01:44,400 --> 02:01:50,520
Very soon after we published that study, 
Wendy Phillips published a study using data  

1072
02:01:50,520 --> 02:01:56,760
from 420 different hospitals that used Morrison 
Healthcare to manage their registered dietitians.  

1073
02:01:57,300 --> 02:02:01,740
This study defined and reported things 
a little bit differently than our study,  

1074
02:02:01,740 --> 02:02:06,120
but they identified that the average 
time per encounter was 25 minutes.  

1075
02:02:06,960 --> 02:02:12,720
This was not separated out by complexity. And 
so, I think that when you consider an average  

1076
02:02:12,720 --> 02:02:22,920
complexity, this is fairly similar to our other 
2015 study. So, to summarize, both 2015 studies  

1077
02:02:22,920 --> 02:02:29,520
used self-reported data and did not collect 
outcome, so, they could not establish an ideal  

1078
02:02:29,520 --> 02:02:34,620
amount of nutrition care time; they could just 
benchmark the amount that's currently provided.  

1079
02:02:35,880 --> 02:02:40,740
There was very little movement forward on the 
question of registered dietitian staffing since  

1080
02:02:40,740 --> 02:02:47,580
these two papers came out. However, in preparing 
for this presentation, I was able to find an  

1081
02:02:47,580 --> 02:02:52,680
interesting case report that was published 
last summer regarding how nutrition staffing  

1082
02:02:52,680 --> 02:02:58,380
was accomplished for the field hospital that was 
set up during the COVID-19 surge in New York City. 

1083
02:02:59,280 --> 02:03:03,900
You can see that this group established 
a number of registered dietitians needed  

1084
02:03:03,900 --> 02:03:08,520
for clinical encounters based on the number 
of beds that were occupied. So, for example,  

1085
02:03:08,520 --> 02:03:15,180
at 250 occupied beds, one full-time 
equivalent was needed. And at 375 beds,  

1086
02:03:15,180 --> 02:03:23,880
two clinical dietitians plus a critical care 
dietitian were needed. But clearly, the gap that  

1087
02:03:23,880 --> 02:03:29,640
remains from all of these studies is the linkage 
between dietitian time and patient outcomes.  

1088
02:03:32,400 --> 02:03:37,920
However, this is quite a complicated linkage 
and something that we've been thinking about  

1089
02:03:37,920 --> 02:03:43,140
for quite a long time. So, I'd like to just 
briefly review some of the considerations that  

1090
02:03:43,140 --> 02:03:48,780
make this linkage complicated. First of all, 
poor nutrition status is closely related to  

1091
02:03:48,780 --> 02:03:54,480
other medical conditions. And so, the time that's 
required for nutrition care and the effectiveness  

1092
02:03:54,480 --> 02:04:00,540
of nutrition interventions provided by registered 
dietitians might be mediated by those underlying  

1093
02:04:00,540 --> 02:04:06,060
medical conditions. Nutrition interventions 
are complex, and they might change over time,  

1094
02:04:06,060 --> 02:04:09,900
meaning multiple nutrition encounters 
that should be captured in the time data. 

1095
02:04:10,800 --> 02:04:16,500
And finally, from a research perspective, 
both of the 2015 studies use the registered  

1096
02:04:16,500 --> 02:04:21,720
dietitians as the subjects and did not collect 
any personal medical information. And so,  

1097
02:04:21,720 --> 02:04:27,000
we did not have to obtain consent and HIPAA 
authorization from the patients. But of course,  

1098
02:04:27,000 --> 02:04:32,040
once you start collecting outcomes, which are 
essential to this question, you do have to collect  

1099
02:04:32,040 --> 02:04:37,380
informed consent and HIPAA authorization. So, that 
complicates the research protocol a little bit.  

1100
02:04:40,200 --> 02:04:45,840
So, the Academy of Nutrition and Dietetics 
has been working on a study to both validate  

1101
02:04:45,840 --> 02:04:52,200
the Academy/ASPEN diagnostic indicators for 
malnutrition and also to look at staffing needs  

1102
02:04:52,200 --> 02:04:58,440
that might be related to malnutrition. The full 
study protocol has been published, and Dr. Alison Steiber  

1103
02:04:58,440 --> 02:05:04,080
will be talking a little bit more about 
the validation portion later in today's session.  

1104
02:05:05,640 --> 02:05:11,580
So, I want to focus in on the staffing 
part of that study and introduce just a  

1105
02:05:11,580 --> 02:05:16,980
little bit of preliminary data so that 
you can understand who participated  

1106
02:05:16,980 --> 02:05:22,260
in this project and where we're going.
So, there were 38 dietitians who provided  

1107
02:05:22,260 --> 02:05:29,760
care and have so far provided adult data to this 
study. And you can see from this side that we  

1108
02:05:29,760 --> 02:05:35,400
have a nice spread of experience and the expected 
distribution of dietitians with a graduate degree.  

1109
02:05:37,500 --> 02:05:42,600
Similarly, for the 37 adult hospitals 
from which we have data at the moment,  

1110
02:05:43,140 --> 02:05:49,920
we have a nice spread in terms of characteristics, 
including a case mix index that's very similar to  

1111
02:05:49,920 --> 02:05:56,640
what we saw in 2015 and a nice spread in terms of 
the urbanicity of the participating facilities.  

1112
02:05:59,220 --> 02:06:05,460
So, this is just some data about the nutrition 
care for adult patients in this study. The  

1113
02:06:05,460 --> 02:06:13,500
dietitian-assessed complexity was low for 16% of 
the patients, moderate for 55% of the patients,  

1114
02:06:13,500 --> 02:06:20,880
and high for 30% of that the patients. So, there's 
fewer high-complexity patients than we had in  

1115
02:06:20,880 --> 02:06:27,600
the 2015 study when we were at almost 40% high 
complexity, but I think that's because of the  

1116
02:06:27,600 --> 02:06:33,300
intermingling of pediatric data in the complexity 
data that I showed earlier in this presentation.  

1117
02:06:34,740 --> 02:06:39,780
When you look at the time required for 
the patient encounters in this data,  

1118
02:06:39,780 --> 02:06:45,720
the average time is about 43 minutes.
And in our 2015 study, it was 31 minutes  

1119
02:06:45,720 --> 02:06:51,600
for high-complexity patients. So, I would 
attribute this difference and the longer  

1120
02:06:51,600 --> 02:06:58,860
length of time in the more recent study because 
this is all initial encounters, and in 2015  

1121
02:06:58,860 --> 02:07:02,100
we included both initial and follow-up encounters.  

1122
02:07:03,060 --> 02:07:10,680
Also in this slide, you can see the proportion 
of patients that were in the ICU, 19%, and the total  

1123
02:07:10,680 --> 02:07:16,740
number of nutrition-support contacts that patients 
received during their 90-day follow-up period.  

1124
02:07:17,580 --> 02:07:24,120
You can also see that about 10% of the patients 
had malnutrition as their nutrition diagnosis.  

1125
02:07:25,860 --> 02:07:31,680
So, clearly, there's a lot more to be done with 
this data from the new study in terms of looking  

1126
02:07:31,680 --> 02:07:36,660
at what patient characteristics predict 
or modulate, the amount of time required,  

1127
02:07:36,660 --> 02:07:41,520
and then looking into the outcomes data to 
determine the linkage between time spent  

1128
02:07:41,520 --> 02:07:46,500
with the patients and staffing level, so 
connecting staffing level to outcomes.  

1129
02:07:47,700 --> 02:07:54,540
I think some other remaining research gaps 
include staffing for other conditions. So,  

1130
02:07:54,540 --> 02:08:03,180
in patient settings, what other non-malnutrition 
conditions might modulate staffing requirements? 

1131
02:08:03,180 --> 02:08:10,380
We should also examine dietitian staffing for 
other specialty areas and settings. For example,  

1132
02:08:10,380 --> 02:08:15,000
we know that there's a lot of work to be done 
with prevention and treatment of malnutrition  

1133
02:08:15,000 --> 02:08:20,460
in follow-up settings, and so, what do 
staffing needs look like in those settings?  

1134
02:08:21,660 --> 02:08:26,100
And then something that's a major interest to 
our clinical nutrition managers and that we  

1135
02:08:26,100 --> 02:08:31,320
have very little data on is how to appropriately 
staff for nutrition care needs on the weekend.  

1136
02:08:32,100 --> 02:08:37,560
And the last thing that I'd like to suggest 
as an important research gap in this area is  

1137
02:08:37,560 --> 02:08:44,280
really thinking about the quadruple aim. So, we 
know that the quadruple aim thinks about worker  

1138
02:08:44,280 --> 02:08:50,400
wellness and preventing burnout and maintaining 
a high-quality healthcare workforce as a way to  

1139
02:08:50,400 --> 02:08:57,780
also improve the quality of patient care. So, when 
we think about the drivers of burnout, you can see  

1140
02:08:57,780 --> 02:09:03,060
in the box I've highlighted three, including 
excessive workload, inefficient processes,  

1141
02:09:03,060 --> 02:09:08,400
and the electronic medical record. And so, all of 
these things are closely aligned with staffing. 

1142
02:09:08,400 --> 02:09:14,340
And as we potentially modulate the number of 
patients the dietitians are asked to care for,  

1143
02:09:14,340 --> 02:09:18,540
we really need to monitor for 
risk factors and signs of burnout.  

1144
02:09:19,260 --> 02:09:23,160
So, thank you, and I look forward to 
answering questions during the live Q&A.

1145
02:09:23,160 --> 02:09:30,660
DR. MARSHA SCHOFIELD: Thank you for the opportunity 
to speak to payment issues related to the  

1146
02:09:30,660 --> 02:09:36,540
identification and treatment of malnutrition 
in the hospital inpatient setting. While I'm  

1147
02:09:36,540 --> 02:09:43,440
going to address payment issues, I can't stress 
enough what, as clinicians, we already know. The  

1148
02:09:43,440 --> 02:09:49,740
primary reason we address malnutrition in hospital 
patients is because we want to provide quality care.  

1149
02:09:50,400 --> 02:09:56,220
At the same time, there are potential revenue 
streams we can tap into to support the delivery of  

1150
02:09:56,220 --> 02:10:02,700
such care, hence why I'm here today to talk about 
payment issues. But first and foremost, we're  

1151
02:10:02,700 --> 02:10:08,280
identifying and treating malnutrition because 
it's the right thing to do for our patients.  

1152
02:10:09,840 --> 02:10:15,360
To understand the payment issues around inpatient 
care for malnourished patients, you first need  

1153
02:10:15,360 --> 02:10:21,480
to understand payment for inpatient care in the 
United States. Let's start by looking at who pays  

1154
02:10:21,480 --> 02:10:28,320
for inpatient hospitalizations. Based on data 
from 2020, the largest proportion of hospital  

1155
02:10:28,320 --> 02:10:35,640
inpatient stays are paid for by private insurance, 
followed by Medicare at 30%, and then Medicaid. 

1156
02:10:36,960 --> 02:10:43,560
But when we look at who pays for stays related 
to malnutrition, this data from 2016 shows  

1157
02:10:43,560 --> 02:10:50,460
Medicare as the expected primary payer for 
almost two-thirds of inpatient stays related  

1158
02:10:50,460 --> 02:10:56,340
to protein-calorie malnutrition. This point is 
important as we look at how payment for inpatient  

1159
02:10:56,340 --> 02:11:03,420
care is determined. While Medicare payments 
for inpatient stays are complex. The simple  

1160
02:11:03,420 --> 02:11:11,640
explanation is that Medicare bases payments on 
diagnosis-related groups or DRGs based on the  

1161
02:11:11,640 --> 02:11:17,940
primary reason for the hospitalization, which 
is actually determined after discharge. Cases  

1162
02:11:17,940 --> 02:11:25,860
are classified into Medicare Severity Diagnosis 
Related Groups or MS-DRGs based on the principal  

1163
02:11:25,860 --> 02:11:32,400
diagnosis and up to 24 additional diagnoses. 
And they're paid at a rate based on the average  

1164
02:11:32,400 --> 02:11:39,600
resources used to treat patients in that DRG. 
In addition, certain diagnoses are designated  

1165
02:11:39,600 --> 02:11:47,460
as a major complication/comorbidity, or 
MCC, or a complication/comorbidity, CC,  

1166
02:11:47,460 --> 02:11:52,560
and may result in a higher Medicare payment 
to account for the more intense levels  

1167
02:11:52,560 --> 02:11:58,740
of care and/or longer lengths of stay.
As you can see, several diagnosis codes  

1168
02:11:58,740 --> 02:12:06,720
for malnutrition are deemed an MCC or CC and may 
qualify for increased reimbursement for Medicare.  

1169
02:12:07,260 --> 02:12:12,480
But for that to happen, not only must 
the medical diagnosis be determined by  

1170
02:12:12,480 --> 02:12:18,000
the physician, but also a plan of care must 
be implemented during the hospitalization.  

1171
02:12:18,600 --> 02:12:27,300
And it takes only one CC or MCC to shift the 
MS-DRG and hence reimbursement. Most state  

1172
02:12:27,300 --> 02:12:34,620
Medicaid programs and private insurances also pay 
based on DRGs, although actual rate may vary from  

1173
02:12:34,620 --> 02:12:40,440
those used by Medicare. It's also important to 
note that while a nutrition care plan developed  

1174
02:12:40,440 --> 02:12:46,440
and implemented by a dietitian is a cornerstone 
of inpatient care for persons with malnutrition, 

1175
02:12:46,440 --> 02:12:52,380
there generally is no separate payment for 
inpatient nutrition consultations and services.  

1176
02:12:54,660 --> 02:12:59,820
As clinicians have done a better job of 
driving quality in patient care by identifying  

1177
02:12:59,820 --> 02:13:05,760
malnutrition, the increase in malnutrition 
diagnoses and associated payments has caught  

1178
02:13:05,760 --> 02:13:13,440
the attention of CMS, as well as private payers. 
In January 2018, the Office of the Inspector  

1179
02:13:13,440 --> 02:13:19,800
General included in its work plan a new project 
to assess the accuracy of Medicare payments  

1180
02:13:19,800 --> 02:13:26,820
for the treatment of severe malnutrition.
They issued their report in July 2020 and  

1181
02:13:27,360 --> 02:13:35,400
with their findings that 173 of 200 claims 
reviewed did not correctly bill Medicare for  

1182
02:13:35,400 --> 02:13:42,120
severe malnutrition diagnosis codes, resulting 
in an estimated overpayment of $1 billion.  

1183
02:13:43,320 --> 02:13:50,400
Then in November 2021, the OIG announced its plan 
to move on to study Medicaid inpatient hospital  

1184
02:13:50,400 --> 02:13:58,080
claims. The report of that audit is anticipated 
sometime next year. What have been the issues  

1185
02:13:58,080 --> 02:14:05,160
identified by the auditors? Unfortunately, despite 
efforts by the Academy of Nutrition and Dietetics,  

1186
02:14:05,160 --> 02:14:11,520
ASPEN, the American Society of Nutrition, and 
the Association of Clinical Documentation and  

1187
02:14:11,520 --> 02:14:17,940
Integrity Specialists to find out the specific 
criteria being used by the various auditors,  

1188
02:14:17,940 --> 02:14:24,120
there's a significant lack of transparency. 
But we learned through a survey we conducted  

1189
02:14:24,120 --> 02:14:30,000
in 2018 of members who had been the subject 
of audits, whether government or private,  

1190
02:14:30,000 --> 02:14:36,600
and through other anecdotal reports, as well as 
conversations with payers, that denials of hospital  

1191
02:14:36,600 --> 02:14:42,120
inpatient claims for severe malnutrition 
are related to one or more of these factors. 

1192
02:14:42,960 --> 02:14:48,480
First, auditors are using criteria or 
definitions of malnutrition that don't  

1193
02:14:48,480 --> 02:14:54,060
align with current knowledge. And they're looking 
for a nutrition care plan that doesn't align with  

1194
02:14:54,060 --> 02:15:00,840
currently accepted clinical practice guidelines. 
Specifically, they want to see evidence of a low  

1195
02:15:00,840 --> 02:15:06,180
serum albumen. They want to see that the 
patient has a low BMI. They also want to  

1196
02:15:06,180 --> 02:15:11,700
see that patients with severe malnutrition are 
treated with enteral or parenteral nutrition.  

1197
02:15:13,500 --> 02:15:18,720
Well, our associations collectively have been 
trying to work with government auditors on  

1198
02:15:18,720 --> 02:15:23,640
their procedures, these issues point to 
several important research opportunities.  

1199
02:15:24,360 --> 02:15:29,820
We need to validate diagnostic criteria 
for malnutrition in adults and children.  

1200
02:15:30,480 --> 02:15:35,460
So, a huge thank you to everyone who's 
currently involved in those validation studies.  

1201
02:15:36,060 --> 02:15:40,920
We also need further research on the 
optimal interventions and outcomes,  

1202
02:15:40,920 --> 02:15:46,860
both clinical and cost, for treating the 
various types of malnutrition. For example,  

1203
02:15:46,860 --> 02:15:52,980
are enteral or parenteral nutrition really 
necessary in all cases of severe malnutrition? 

1204
02:15:53,640 --> 02:15:59,100
Which malnourished patient populations 
benefit from specific types of interventions?

1205
02:15:59,640 --> 02:16:05,820
And how do we best pay for the identification and 
treatment of malnutrition across the entire care  

1206
02:16:05,820 --> 02:16:13,260
continuum? As I said at the beginning, our primary 
impetus for identifying and treating malnutrition  

1207
02:16:13,260 --> 02:16:19,500
in the hospital setting should be quality care. 
At the same time, we can't ignore the fact that  

1208
02:16:19,500 --> 02:16:24,420
healthcare is moving in the direction of 
linking payment with quality and value.  

1209
02:16:25,200 --> 02:16:31,440
As we saw, Medicare and other payers recognize the 
additional resources needed to treat inpatients  

1210
02:16:31,440 --> 02:16:36,660
with malnutrition. And many hospitals are 
leveraging the increased payments to fund  

1211
02:16:36,660 --> 02:16:43,080
more RDN positions. But there's a new opportunity 
to impact inpatient revenue streams and support  

1212
02:16:43,080 --> 02:16:49,200
research endeavors around malnutrition care. 
And that's through the global malnutrition  

1213
02:16:49,200 --> 02:16:56,460
composite score, the first nutrition quality 
measure, which CMS just adopted as part of the  

1214
02:16:56,460 --> 02:17:02,580
hospital inpatient quality reporting system. 
This quality measure pulls together data on  

1215
02:17:02,580 --> 02:17:08,640
the four essential steps in malnutrition 
care - screening, nutrition assessment,  

1216
02:17:09,359 --> 02:17:16,799
documentation of a diagnosis of malnutrition, and 
developing and implementing a nutrition care plan. 

1217
02:17:17,640 --> 02:17:24,479
Beginning January of 2024, hospitals can elect 
to report on the global malnutrition composite  

1218
02:17:24,479 --> 02:17:32,459
score as one of their three voluntary electronic 
clinical quality measures. If the hospital meets  

1219
02:17:32,460 --> 02:17:39,359
CMS criteria for reporting under the hospital 
inpatient quality reporting system, they can avoid  

1220
02:17:39,359 --> 02:17:46,620
a .2 for 5% reduction in their payments. Use 
of this composite measure will not only support  

1221
02:17:46,620 --> 02:17:53,700
quality malnutrition care, but it provides a 
financial incentive for doing so. Plus, it offers a  

1222
02:17:53,700 --> 02:17:59,760
valuable tool to support research on both clinical 
and financial outcomes of malnutrition care.  

1223
02:18:01,140 --> 02:18:05,640
Thank you again for the opportunity 
to share these insights with you as  

1224
02:18:05,640 --> 02:18:10,260
we all work together to address the gaps 
in our knowledge related to malnutrition  

1225
02:18:10,260 --> 02:18:16,140
in clinical settings with the ultimate goal of 
improving health outcomes and quality of life.

1226
02:18:16,140 --> 02:18:22,080
DR. KEN NEPPLE: Good afternoon. My name is Ken 
Nepple, and I'm a urologist who specializes in  

1227
02:18:22,080 --> 02:18:27,000
cancer treatment. I appreciate the invitation 
to talk about malnutrition diagnosis during  

1228
02:18:27,000 --> 02:18:35,820
adult inpatient hospitalizations. Ten minutes 
will go very quickly. So, I'm going to focus  

1229
02:18:35,820 --> 02:18:41,700
on two topics. First, I'm going to discuss different 
definitions of malnutrition in adults. And second,  

1230
02:18:41,700 --> 02:18:48,359
we're going to focus on the variation in the prevalence 
of malnutrition as malnutrition is noted much more  

1231
02:18:48,359 --> 02:18:54,179
commonly when using nutritional screening or 
dietitian evaluation versus less commonly when  

1232
02:18:54,180 --> 02:19:00,000
using physician hospital diagnosis data. In 
addition, we'll take a look at some efforts  

1233
02:19:00,000 --> 02:19:04,620
we have made to improve documentation to 
bridge that gap. Along the way, I'll try to  

1234
02:19:04,620 --> 02:19:12,540
identify potential opportunities in malnutrition 
research. Missing malnutrition in hospitalized  

1235
02:19:12,540 --> 02:19:18,359
patients is not a new concept. This seminal paper 
by Charles Butterworth was published 43 years ago.  

1236
02:19:18,359 --> 02:19:23,160
However, contemporary literature continues 
to show that malnutrition is underdiagnosed. 

1237
02:19:23,160 --> 02:19:28,200
This summary information for the Malnutrition 
Quality Improvement Initiative notes the often  

1238
02:19:28,200 --> 02:19:33,240
cited figure that 20 to 50% of hospitalized 
patients have malnutrition versus only  

1239
02:19:33,240 --> 02:19:39,420
8% rate of malnutrition diagnosis based on 
administrative data looking at hospital diagnoses.  

1240
02:19:42,540 --> 02:19:48,300
Why does this gap exist? One aspect to acknowledge 
is that prevalence will vary based on definition.  

1241
02:19:49,080 --> 02:19:52,260
It makes common sense that before you 
measure something, you need to define  

1242
02:19:52,260 --> 02:19:57,960
it. In the context of this NIH workshop, it's 
notable that if you go to write a grant that  

1243
02:19:57,960 --> 02:20:03,899
terms are clearly defined, with one term having one 
definition. However, in the nutrition literature 

1244
02:20:03,899 --> 02:20:07,859
and in clinical practice, the one term 
"malnutrition" can have many definitions.  

1245
02:20:10,080 --> 02:20:16,920
Let's look at a few definitions over time. The 
WHO document in 1999 was focused almost entirely  

1246
02:20:16,920 --> 02:20:23,040
on severely malnourished children. However, 
one figure had a BMI cutoff of less than 16,  

1247
02:20:23,040 --> 02:20:29,640
as required for a diagnosis of severe 
malnutrition in adults. Obviously, that  

1248
02:20:29,640 --> 02:20:35,400
definition lacks clinical validity, as patients 
with obesity can still develop malnutrition. 

1249
02:20:36,180 --> 02:20:41,760
Over time, there have been multiple nutritional 
scores that were developed, and while each had  

1250
02:20:41,760 --> 02:20:50,280
value, the lack of a consensus definition was a 
significant barrier. In response, a 2012 consensus  

1251
02:20:50,280 --> 02:20:56,160
statement was developed based on having at least 
two of six clinical characteristics, including  

1252
02:20:56,160 --> 02:21:04,080
inadequate energy intake, weight loss, fat loss, 
muscle loss, edema, or reduced grip strength.  

1253
02:21:04,080 --> 02:21:08,700
Surveys have shown this is the predominant 
current method for malnutrition assessment.  

1254
02:21:11,100 --> 02:21:15,300
More recently, the GLIM 
criteria was published in 2019.  

1255
02:21:16,200 --> 02:21:22,559
That criteria was developed from a ranking of 
different characteristics. This group advocated  

1256
02:21:22,560 --> 02:21:27,600
for keeping the criteria of weight loss, 
muscle loss, and decreased intake, with the  

1257
02:21:27,600 --> 02:21:33,121
addition of an option of a BMI threshold and an 
acknowledgment of disease burden and inflammation.  

1258
02:21:34,500 --> 02:21:42,359
The GLIM criteria require an etiologic criteria as 
above. Then a phenotypic criteria is used to grade  

1259
02:21:42,359 --> 02:21:48,479
the severity based on meeting one of these three 
different characteristics. Regarding the multiple  

1260
02:21:48,479 --> 02:21:53,160
definitions of malnutrition, opportunities exist 
for comparative effectiveness research evaluating  

1261
02:21:53,160 --> 02:22:00,479
which criteria are best associated with outcomes.
Also, it should be noted that more stringent  

1262
02:22:00,479 --> 02:22:05,339
criteria may potentially increase the risk 
of missing malnutrition in some patients.  

1263
02:22:09,240 --> 02:22:13,679
My earliest clinical memories of malnutrition 
assessment as a surgical resident were checking  

1264
02:22:13,680 --> 02:22:18,479
albumen and pre-albumen levels. Notably 
absent from the consensus statement and  

1265
02:22:18,479 --> 02:22:23,700
the consensus report are these laboratory 
assessments, with the stated exception that  

1266
02:22:23,700 --> 02:22:28,080
CRP can be used as a supportive 
lab to evaluate for inflammation.  

1267
02:22:28,920 --> 02:22:34,800
As a clinician who practices in 
cancer and oftentimes uses biomarkers,  

1268
02:22:34,800 --> 02:22:41,220
it can be stated that an unmet need is to 
develop an accurate biomarker in malnutrition.  

1269
02:22:42,660 --> 02:22:47,340
Let's transition into looking at the prevalence 
of malnutrition during adult hospitalizations.  

1270
02:22:49,140 --> 02:22:55,380
In 2008, Norman and colleagues did a review of 
20 different prospective and retrospective studies,  

1271
02:22:55,380 --> 02:22:58,859
which were aimed at determining the 
rate of malnutrition in hospitalized  

1272
02:22:58,859 --> 02:23:06,000
patients and reported a range varying 
from 20 to 50%. However, in contrast,  

1273
02:23:06,000 --> 02:23:13,200
a study assessing malnutrition diagnosis from 
discharge data of more than 39 million patients  

1274
02:23:13,200 --> 02:23:22,319
between 1993 and 2010 found that the reported 
rate of malnutrition diagnosis was only 3.2%. 

1275
02:23:22,319 --> 02:23:26,759
However, that report had noted that 
the rate was increasing some over time.  

1276
02:23:29,460 --> 02:23:35,220
After that prior 2010 report, 
our group wondered, "Did the 2012  

1277
02:23:35,220 --> 02:23:41,040
consensus statement impact the diagnosis of 
malnutrition during hospitalizations?" Also,  

1278
02:23:41,040 --> 02:23:47,220
could it be that academic medical centers did 
a better job of diagnosing malnutrition? Our  

1279
02:23:47,220 --> 02:23:52,500
group added to the literature by evaluating 
a database of academic medical centers. That  

1280
02:23:52,500 --> 02:23:58,859
database was called UHC, but it's now called 
Vizient. We were able to look back and see how  

1281
02:23:58,859 --> 02:24:05,700
many patients had malnutrition diagnosed 
during hospital stays in 2014 and 2015.  

1282
02:24:07,680 --> 02:24:14,040
However, our findings noted that malnutrition 
diagnosis continued to be infrequent, as only  

1283
02:24:14,040 --> 02:24:24,660
5% of adult inpatients had a malnutrition diagnosis 
in 2014 and 2015. Subsequently, our group sought  

1284
02:24:24,660 --> 02:24:30,540
to improve the malnutrition assessment process by 
using technology-enabled workflow to bridge that  

1285
02:24:30,540 --> 02:24:39,359
gap between dietitian assessment and physician 
diagnosis. In 2014, I invited myself onto a  

1286
02:24:39,359 --> 02:24:44,519
malnutrition pilot project at our hospital.
To my benefit, I was the only physician that  

1287
02:24:44,520 --> 02:24:48,479
showed up to the initial meeting. I got the 
opportunity to work with our hospital group,  

1288
02:24:48,479 --> 02:24:54,359
where we evaluated the patient process from 
pre-admission to admission nursing screening,  

1289
02:24:54,359 --> 02:24:59,339
then nutrition dietitian consult, then 
to provider diagnosis and treatment.  

1290
02:25:01,319 --> 02:25:07,979
By understanding the process and where 
data did and did not exist, we were able  

1291
02:25:07,979 --> 02:25:16,019
to identify gaps and opportunities for improved 
workflow. We took the 2012 consensus statement  

1292
02:25:18,060 --> 02:25:23,580
and operationalized it within the electronic 
health record. The details are beyond the scope  

1293
02:25:23,580 --> 02:25:29,100
of this presentation, but in short summary, we 
created workflows that added discrete data to the  

1294
02:25:29,100 --> 02:25:34,500
dietitian assessment and made that information 
readily available to providers to use in their  

1295
02:25:34,500 --> 02:25:38,939
clinical practice and their documentation 
and progress notes and discharge summaries.  

1296
02:25:40,620 --> 02:25:44,399
Remarkably, the pilot showed 
that with this workflow,  

1297
02:25:44,399 --> 02:25:48,719
physicians could document more consistently 
which of their patients had evidence of  

1298
02:25:48,720 --> 02:25:52,920
malnutrition, as the malnutrition 
diagnosis rate increased to 42%. 

1299
02:25:54,359 --> 02:25:59,580
The pilot workflow was subsequently implemented 
housewide and contributed to institutional  

1300
02:25:59,580 --> 02:26:05,280
support for nutritional care, including more 
dietitians and ultimately development of an  

1301
02:26:05,280 --> 02:26:10,200
advanced nutritional support inpatient consult 
service that is staffed by a gastroenterologist.  

1302
02:26:13,200 --> 02:26:19,920
Over time, this process has continued to 
evolve and has shown sustained growth in  

1303
02:26:19,920 --> 02:26:22,560
the accurate identification of malnutrition.  

1304
02:26:25,319 --> 02:26:30,660
In closing, with the last couple of minutes, as a 
cancer surgeon, I want to specifically advocate  

1305
02:26:30,660 --> 02:26:37,500
for malnutrition research in cancer patients. 
The momentum is starting to build for nutritional  

1306
02:26:37,500 --> 02:26:41,819
optimization in cancer patients, who are at 
high risk of malnutrition due to the catabolic  

1307
02:26:41,819 --> 02:26:48,540
nature of cancer. Here are a few examples 
of work advocating for nutritional research  

1308
02:26:48,540 --> 02:26:53,580
and cancer patients, and a summary paragraph 
that I had drafted in a prior grant proposal.  

1309
02:26:56,460 --> 02:27:00,300
As one example, bladder cancer patients who have  

1310
02:27:00,300 --> 02:27:05,580
muscle invasive disease require major surgery 
with radical cystectomy and urinary diversion. 

1311
02:27:08,040 --> 02:27:12,600
Enhanced recovery protocols are now widely 
utilized in this cystectomy population.  

1312
02:27:12,600 --> 02:27:19,319
And specifically, there's an ongoing SWOG 
randomized trial to look at the potential  

1313
02:27:19,319 --> 02:27:25,740
benefit of immunonutrition compared to placebo in 
cystectomy patients. Further research is needed  

1314
02:27:25,740 --> 02:27:31,019
to evaluate which nutritional interventions 
have the most impact in surgical patients.  

1315
02:27:33,359 --> 02:27:38,280
Here is a schematic that we developed on 
taking a multidisciplinary approach to  

1316
02:27:38,280 --> 02:27:40,500
malnutrition assessment in surgical populations.  

1317
02:27:43,319 --> 02:27:48,000
I borrowed this slide from Dr. Sarah Psutka, 
who's a urologic oncologist at the University  

1318
02:27:48,000 --> 02:27:55,380
of Washington, with her permission. Notably, they 
used radiographic assessments with CTs to evaluate  

1319
02:27:55,380 --> 02:28:02,340
for sarcopenia. Even when controlling for standard 
TNM staging and other clinical characteristics,  

1320
02:28:02,340 --> 02:28:09,060
they found that sarcopenia was associated 
with worse survival after radical cystectomy,  

1321
02:28:09,060 --> 02:28:14,160
even when controlling on multivariate 
analysis. This really brings up the potential  

1322
02:28:14,160 --> 02:28:20,099
opportunity for radiomics to establish a 
radiographic biomarker for malnutrition. 

1323
02:28:21,180 --> 02:28:30,359
Lastly, 35 randomized controlled trials had been 
published on the use of arginine supplementation  

1324
02:28:30,359 --> 02:28:37,019
in surgical patients. However, these results 
have not been widely disseminated. For example,  

1325
02:28:37,020 --> 02:28:42,240
when I first learned about this, I discussed 
with our colorectal surgeon at my institution,  

1326
02:28:42,240 --> 02:28:46,200
and they were not even aware of these protocols 
even though they had been developed in the  

1327
02:28:46,200 --> 02:28:52,620
colorectal population. This is an opportunity for 
further dissemination and implementation research.  

1328
02:28:54,479 --> 02:28:58,740
Thanks again for the invitation, and I'm 
very much looking forward to the workshop.

1329
02:28:58,740 --> 02:29:04,800
DR. MEAGAN GREGA: Hi, everyone. I'm Meagan Grega, a 
family medicine doc who is also board certified  

1330
02:29:04,800 --> 02:29:09,479
in lifestyle medicine, and the Co-founder and 
Chief Medical Officer of Kellyn Foundation. Thank  

1331
02:29:09,479 --> 02:29:13,379
you for inviting me to talk about the amazing 
potential of lifestyle medicine approaches  

1332
02:29:13,380 --> 02:29:18,120
for patients with malnutrition, along with the 
challenges in implementing those programs due  

1333
02:29:18,120 --> 02:29:23,460
to reimbursement issues. Some of my favorite words 
of wisdom on how to approach a challenge come from  

1334
02:29:23,460 --> 02:29:28,439
Albert Einstein. He said, "We cannot solve our 
problems with the same thinking we used when we  

1335
02:29:28,439 --> 02:29:33,660
created them." As we grapple with the epidemic of 
chronic disease and years of quality life lost in  

1336
02:29:33,660 --> 02:29:37,979
our country, the search for innovative solutions 
must include lifestyle medicine approaches,  

1337
02:29:37,979 --> 02:29:43,620
especially those focused on optimal nutrition. 
And unfortunately, despite our high-tech medical  

1338
02:29:43,620 --> 02:29:47,880
care and pharmaceutical interventions, we are 
not succeeding in our quest to improve health,  

1339
02:29:47,880 --> 02:29:52,260
vitality, and longevity. We've had several 
years of decreasing life expectancy in  

1340
02:29:52,260 --> 02:29:57,420
the U.S. even before the COVID-19 pandemic.
The decreases in life expectancy were largely  

1341
02:29:57,420 --> 02:30:02,700
related to increases in all-cause mortality in 
young and middle-aged adults, with a significant  

1342
02:30:02,700 --> 02:30:07,439
contribution from organ system diseases like 
hypertension, diabetes, cardiovascular disease,  

1343
02:30:07,439 --> 02:30:12,719
and obesity. What this data shows us is that 
while our pills and procedures are helpful  

1344
02:30:12,720 --> 02:30:17,520
in slowing the trajectory of chronic disease, 
they are not able to fully combat the effect of  

1345
02:30:17,520 --> 02:30:22,439
lifestyle choices that increase our risk of death 
and disability. For a country that spends over  

1346
02:30:22,439 --> 02:30:28,500
$11,500 per person every year on health care, we 
are not getting a good return on our investment.  

1347
02:30:28,500 --> 02:30:32,399
And when we look at the risk factors that are 
causing a decrease in healthy life expectancy,  

1348
02:30:32,399 --> 02:30:35,879
we find several that are often related 
to the food choices we consume,  

1349
02:30:35,880 --> 02:30:41,580
such as high BMI, poor diet, alcohol use, 
high fasting blood sugar, and hypertension.  

1350
02:30:42,120 --> 02:30:48,180
Now, the good news is we can do better. A research 
paper published in February utilizing data from  

1351
02:30:48,180 --> 02:30:53,580
the 2019 Global Burden of Disease study evaluated 
the impact on life expectancy when switching from  

1352
02:30:53,580 --> 02:30:58,500
a standard Western diet to an optimal diet.
This diet is not a vegan or even a vegetarian  

1353
02:30:58,500 --> 02:31:03,899
diet, but it is a plant predominant, minimally 
processed diet. Transitioning to an optimal diet  

1354
02:31:03,899 --> 02:31:08,759
from a Western diet at age 20 resulted in 
over 10 years of increased life expectancy,  

1355
02:31:08,760 --> 02:31:14,520
with even greater increases seen for men. Just 
as exciting, transitioning at age 60 or even  

1356
02:31:14,520 --> 02:31:19,800
80 results in significant years of life gained. 
This study highlights the importance of food as  

1357
02:31:19,800 --> 02:31:24,360
medicine initiatives that support and encourage 
patients to transition to healthier choices.  

1358
02:31:25,080 --> 02:31:29,460
But unfortunately, this study published in March 
highlights how much work we still have to do to  

1359
02:31:29,460 --> 02:31:34,200
shift the social norms of our country towards 
healthy eating habits. NHANES data evaluated  

1360
02:31:34,200 --> 02:31:38,819
diet quality scores for adults 65 and older
and found that the proportion of adults with  

1361
02:31:38,819 --> 02:31:46,500
poor diet quality increased from 51% to 61%. Those 
with intermediate diet quality decreased from 49%  

1362
02:31:46,500 --> 02:31:55,260
to 39%. And those with ideal diet quality remained 
consistently low at 0.4%. So, regarding healthy  

1363
02:31:55,260 --> 02:32:00,420
lifestyles, there's no lack of information.
There is lack of implementation. And  

1364
02:32:00,420 --> 02:32:05,100
implementation is the goal of the American College 
of Lifestyle Medicine. Lifestyle medicine is the  

1365
02:32:05,100 --> 02:32:09,420
evidence-based practice of helping individuals 
and communities with comprehensive lifestyle  

1366
02:32:09,420 --> 02:32:14,880
changes to help prevent, treat, and even reverse 
the progression of chronic diseases by addressing  

1367
02:32:14,880 --> 02:32:20,280
the underlying causes. So, a major barrier to 
successful implementation of lifestyle medicine  

1368
02:32:20,280 --> 02:32:24,840
approaches, including those focused on supporting 
patients in their transition to optimal nutrition,  

1369
02:32:24,840 --> 02:32:30,120
is the current reimbursement landscape. There 
are many obstacles to providing comprehensive  

1370
02:32:30,120 --> 02:32:34,920
lifestyle medicine services, but I would like to 
highlight four main areas today—fee-for-service  

1371
02:32:34,920 --> 02:32:39,420
models that do not adequately support the delivery 
or the reimbursement of Lifestyle Medicine care; 

1372
02:32:39,960 --> 02:32:43,439
inadequate payment level for billing 
codes associated with lifestyle change; 

1373
02:32:44,040 --> 02:32:48,180
insufficient accessibility of Intensive 
Therapeutic Lifestyle Change Programs for  

1374
02:32:48,180 --> 02:32:52,319
patients due to inadequate reimbursement or 
administrative challenges with licensing and  

1375
02:32:52,319 --> 02:32:55,500
reporting requirements, and lack of 
reimbursement for "Food as Medicine"  

1376
02:32:55,500 --> 02:32:59,100
strategies, such as "Healthy Food" Prescription 
Vouchers and Medically Tailored Meals. 

1377
02:32:59,100 --> 02:33:02,700
Let's dive into the first 
two areas in more detail.

1378
02:33:02,700 --> 02:33:08,819
A recent clinician survey by ACLM 
revealed that 55% of respondents reported  

1379
02:33:08,819 --> 02:33:11,700
not being able to achieve reimbursement 
for their Lifestyle Medicine services.  

1380
02:33:11,700 --> 02:33:17,280
The current RVU system pays for volume of 
care, not for performance or outcomes. So,  

1381
02:33:17,280 --> 02:33:21,240
this focus on quantity over quality 
penalizes providers engaged in the  

1382
02:33:21,240 --> 02:33:25,200
long-term relationship building and frequent 
support necessary for effective behavior change.  

1383
02:33:25,920 --> 02:33:29,580
Additionally, there are misaligned incentives 
and quality measures that reward medication  

1384
02:33:29,580 --> 02:33:33,960
prescribing, such as statins, and penalize 
deprescribing when lifestyle changes have  

1385
02:33:33,960 --> 02:33:38,880
improved biometrics. Practitioners can have 
financial consequences when they successfully help  

1386
02:33:38,880 --> 02:33:43,319
patients improve their lifestyle choices and then 
deprescribe medications that are no longer needed.  

1387
02:33:44,580 --> 02:33:49,260
The very nature of lifestyle medicine requires 
longer and more frequent visits to support  

1388
02:33:49,260 --> 02:33:53,460
behavior change, which is often best delivered 
in a group setting, such as a shared medical  

1389
02:33:53,460 --> 02:33:58,800
appointment. But in these scenarios, patient 
co-pays for frequent visits are often a deterrent. 

1390
02:33:58,800 --> 02:34:03,120
Additionally, the place of service 
NPI number limits access for patients  

1391
02:34:03,120 --> 02:34:06,840
in community settings, such as schools, 
places of worship, and teaching kitchens,  

1392
02:34:06,840 --> 02:34:11,040
which may be more convenient and accessible 
gathering places, rather than holding all sessions  

1393
02:34:11,040 --> 02:34:15,899
in a health care facility. There's often limited 
or no reimbursement for interdisciplinary care  

1394
02:34:15,899 --> 02:34:20,040
team members, and one of the most urgent matters 
to address is that the Medicare coverage for  

1395
02:34:20,040 --> 02:34:24,420
medical nutrition therapy is currently only for 
patients with diabetes and chronic kidney disease,  

1396
02:34:24,420 --> 02:34:28,080
when so many other patients with chronic 
nutritionally related diseases could benefit.  

1397
02:34:29,160 --> 02:34:33,599
Another issue is the inadequate payment level 
for billing codes associated with lifestyle  

1398
02:34:33,600 --> 02:34:39,060
change. Many of us are familiar with the common 
99213 office visit code that typically covers a  

1399
02:34:39,060 --> 02:34:45,360
15-to 20-minute visit with a patient. A typical 
level of reimbursement for a 99213 is $92.47.  

1400
02:34:46,800 --> 02:34:50,640
Contrast that with spending the same 15 
minutes with a patient but counseling on  

1401
02:34:50,640 --> 02:34:54,840
lifestyle choices to address obesity and assisting 
the patient with education and goal setting. 

1402
02:34:54,840 --> 02:35:01,140
If you use the G0447 code for intensive behavioral 
therapy for obesity, your reimbursement drops to  

1403
02:35:01,140 --> 02:35:06,660
$26.31. If you choose to provide the educational 
content and goal setting in a shared medical  

1404
02:35:06,660 --> 02:35:10,200
appointment, which is a very effective and 
efficient way to engage several patients with  

1405
02:35:10,200 --> 02:35:15,240
the same condition and provide support as part 
of the therapeutic modality, a 30-minute visit  

1406
02:35:15,240 --> 02:35:21,540
is reimbursed at only $12.97 per patient. A 
similar scenario plays out with the diabetes  

1407
02:35:21,540 --> 02:35:26,760
self-management codes, both individual and group. 
These payment rates do not add up to sustainable  

1408
02:35:26,760 --> 02:35:31,140
reimbursement for the vital and necessary role 
of lifestyle counseling for optimal behavior  

1409
02:35:31,140 --> 02:35:35,340
choices that we know creates the foundation for 
prevention and treatment of chronic disease.  

1410
02:35:36,180 --> 02:35:39,120
So, what are some of the research 
opportunities to improve this situation?  

1411
02:35:39,780 --> 02:35:45,059
First, let's quantify the improvement in clinical 
outcomes and just as importantly, the return on  

1412
02:35:45,060 --> 02:35:49,500
investment for intensive therapeutic lifestyle 
change programs. Programs like the Diabetes  

1413
02:35:49,500 --> 02:35:54,120
Prevention Program and Intensive Cardiac Rehab 
have demonstrated impressive clinical outcomes. 

1414
02:35:54,120 --> 02:35:58,800
But despite these clinical outcomes, 
accessibility of ITLC programs are often  

1415
02:35:58,800 --> 02:36:04,920
limited by reimbursement issues and licensure 
requirements. For example, the maximum Medicare  

1416
02:36:04,920 --> 02:36:10,439
DPP payment is $705 for an entire year-long 
program if all metrics of weight loss and  

1417
02:36:10,439 --> 02:36:15,719
attendance are achieved, which is less than the 
reimbursement achieved with eight 99213 visits,  

1418
02:36:15,720 --> 02:36:19,320
something most physicians can complete 
over a 2-hour time frame in the clinic.  

1419
02:36:20,460 --> 02:36:24,840
Next, let's evaluate the effectiveness of healthy 
food prescription vouchers for patients with  

1420
02:36:24,840 --> 02:36:29,160
chronic diseases related to malnutrition. 
The Health Incentive Pilot program for SNAP  

1421
02:36:29,160 --> 02:36:34,439
beneficiaries was a great start in this direction. 
It provided a 30% incentive for every dollar spent  

1422
02:36:34,439 --> 02:36:39,960
on targeted fruits and vegetables for 12 months in 
a randomized population of SNAP beneficiaries. It  

1423
02:36:39,960 --> 02:36:44,340
found significant improvements in fruit and 
vegetable consumption, and cost-effective  

1424
02:36:44,340 --> 02:36:50,939
analysis predicted a net cost savings of $824 
per capita. If we are willing to pay for blood  

1425
02:36:50,939 --> 02:36:55,200
pressure meds and diabetes drugs, why aren't 
we willing to pay for broccoli and legumes? 

1426
02:36:55,200 --> 02:36:59,340
The only side effects will be good ones, and 
the health care savings will accrue every year.  

1427
02:37:00,240 --> 02:37:04,500
There are so many great research opportunities to 
talk about, but I would like to end with assessing  

1428
02:37:04,500 --> 02:37:08,939
the impact of medically tailored meals. Studies 
of medically tailored meals have been small,  

1429
02:37:08,939 --> 02:37:13,200
secondary to resource constraints, but those 
that have been done are associated with fewer  

1430
02:37:13,200 --> 02:37:18,540
inpatient and skilled nursing facility admissions 
and approximately 16% net health care cost savings 

1431
02:37:18,540 --> 02:37:24,600
and a 50% increase in medication adherence. In 
closing, there's compelling evidence that focusing  

1432
02:37:24,600 --> 02:37:29,220
on optimizing nutrition will improve patient 
longevity and vitality while decreasing health  

1433
02:37:29,220 --> 02:37:34,620
care costs. So, here are some calls to action. 
Contact your elected representatives and urge  

1434
02:37:34,620 --> 02:37:39,180
them to pass the MNT Act. This legislation 
will significantly increase the number of  

1435
02:37:39,180 --> 02:37:43,800
chronic disease diagnoses: that are eligible 
for medical nutrition therapy reimbursement.  

1436
02:37:44,340 --> 02:37:49,140
Remove the place of service NPI requirements for 
community locations, making group visits where  

1437
02:37:49,140 --> 02:37:53,100
people live, work, and play more accessible 
and sustainable from a funding standpoint. 

1438
02:37:53,700 --> 02:37:57,059
Create payment models that allow for 
longer and more frequent appointments,  

1439
02:37:57,060 --> 02:38:01,020
and also advocate for reimbursement 
for the interdisciplinary team members.  

1440
02:38:01,680 --> 02:38:05,399
Change the co-payment requirements for 
patients engaged in Intensive Therapeutic  

1441
02:38:05,399 --> 02:38:08,819
Lifestyle Change programs or frequent shared 
medical appointments for chronic disease  

1442
02:38:08,819 --> 02:38:14,460
management to remove that financial barrier for 
patient participation. Reform quality measures  

1443
02:38:14,460 --> 02:38:18,240
that incentivize medication prescribing, 
such as statins and diabetes medications,  

1444
02:38:18,240 --> 02:38:23,760
as opposed to patient outcome metrics. And 
lastly, provide reimbursement models for Medically  

1445
02:38:23,760 --> 02:38:27,780
Tailored Meals and Healthy Food prescription 
vouchers. Thank you so much for allowing me  

1446
02:38:27,780 --> 02:38:31,800
to speak with you about both the potential and 
the pitfalls of lifestyle medicine reimbursement,  

1447
02:38:31,800 --> 02:38:35,640
and I look forward to an invigorating 
conversation during the panel discussion.

1448
02:38:35,640 --> 02:38:46,800
DR. KELLY TAPPENDEN: Thank you so much for that. Thank 
you, I want to thank each of you for your  

1449
02:38:46,800 --> 02:38:51,240
great presentations. To our audience, please 
do share the questions you have in the chat  

1450
02:38:51,240 --> 02:39:00,000
box, and I will try and make sure that we get 
to all of them as we go through. So, Dr. Grega,  

1451
02:39:00,000 --> 02:39:06,540
thank you very much for that great presentation. 
I was impressed with the list, the calls of action  

1452
02:39:06,540 --> 02:39:12,600
that you had to the end there. How do we as 
individuals impact that legislation, though?

1453
02:39:12,600 --> 02:39:19,741
DR. MEAGAN GREGA: That is an excellent question. 
But as we are all voters, and we all have  

1454
02:39:20,460 --> 02:39:25,260
representatives that we can talk to, I think 
it's the most important thing is getting the  

1455
02:39:25,260 --> 02:39:31,439
information out there about how ridiculous it is 
that we pay so much money on the current state of  

1456
02:39:31,439 --> 02:39:35,639
how we take care of patients. And of course, we 
still need to be able to do all the things like,  

1457
02:39:35,640 --> 02:39:39,720
you know, it's interesting my presentation 
was mostly about outpatient versus inpatient,  

1458
02:39:39,720 --> 02:39:42,720
which was what a lot of the other 
presenters were talking about. Now,  

1459
02:39:42,720 --> 02:39:49,260
we definitely still need all that inpatient and 
medication and procedure accessibility. But as  

1460
02:39:49,260 --> 02:39:55,800
we know from our disease statistics, if you are 
going to have an acute illness or a car accident  

1461
02:39:55,800 --> 02:40:00,720
or something like that, the United States is a 
fabulous place to get your health care. If you  

1462
02:40:00,720 --> 02:40:06,720
have a chronic disease, then it's not doing so 
well for your longevity and your outcome. So,  

1463
02:40:06,720 --> 02:40:13,740
I think just showing that if you are going to 
see a patient and spend 15 minutes talking to  

1464
02:40:13,740 --> 02:40:18,359
them about medication, that your physician is 
going to get paid four times more than if they're  

1465
02:40:18,359 --> 02:40:22,859
going to counsel you about what you're eating.
And your lifestyle is something that most of  

1466
02:40:22,859 --> 02:40:27,899
our elected representatives would not realize. 
And they would not realize how low the Diabetes  

1467
02:40:27,899 --> 02:40:34,019
Prevention Program reimbursement is when we know 
that people who have diabetes spend  thousands of  

1468
02:40:34,020 --> 02:40:39,180
dollars more every year on health care costs. So, 
if we could prevent that or if we could prevent  

1469
02:40:39,180 --> 02:40:46,080
that trends, the transition from pre-diabetes 
to diabetes, we could save a lot of money. So,  

1470
02:40:46,080 --> 02:40:51,300
mostly, I think it's advocacy, awareness, 
and explaining to people the differences  

1471
02:40:51,300 --> 02:40:57,180
between how different services are reimbursed 
because I think that's a real black box for  

1472
02:40:57,180 --> 02:41:00,840
most people. We have no idea when we go to 
the doctor or when we go to the dietician or  

1473
02:41:00,840 --> 02:41:05,180
go to any of our health care facilities, what 
the costs are and what the reimbursement is.

1474
02:41:05,180 --> 02:41:09,899
DR. KELLY TAPPENDEN: Is there a coordinated 
letter-writing campaign that's  

1475
02:41:09,899 --> 02:41:13,920
available to help us as we contact 
our representatives and senators?

1476
02:41:13,920 --> 02:41:17,580
DR. MEAGAN GREGA: You know, that's an excellent 
question. I believe the American College of  

1477
02:41:17,580 --> 02:41:22,439
Lifestyle Medicine is doing that for the Medical 
Nutrition Therapy Act. But other than that,  

1478
02:41:22,439 --> 02:41:28,319
it is more of a one-on-one going and talking 
to your representatives. But I would recommend  

1479
02:41:28,319 --> 02:41:31,620
people get in touch with the American College 
of Lifestyle Medicine because they do have  

1480
02:41:31,620 --> 02:41:37,019
staff members that are working on advocacy 
in Washington and on a state-by-state level.

1481
02:41:38,640 --> 02:41:49,859
DR. KELLY TAPPENDEN: Alright, thank you. I want to start 
by asking Dr. Hand, how do you recommend that  

1482
02:41:49,859 --> 02:41:56,219
clinical nutrition managers take into account or 
action the data that she shared with us? And do we  

1483
02:41:56,220 --> 02:42:02,520
know beyond the hospitals that you looked at our 
current staffing levels for registered dieticians?

1484
02:42:02,520 --> 02:42:10,620
DR. ROSA HAND: Yeah, thanks, Kelly. So, I think we've 
heard from some clinical managers that they have  

1485
02:42:10,620 --> 02:42:19,380
been able to use the equations that we present 
based on the 2015 data to successfully compare  

1486
02:42:19,380 --> 02:42:25,920
their current staffing to the current or at 
least eight years ago staffing figures other  

1487
02:42:25,920 --> 02:42:31,979
similar facilities. And in some cases, they've 
been able to use that data to demonstrate that  

1488
02:42:31,979 --> 02:42:39,120
they need more staff. I think at this point, 
we have not done enough analysis of the new  

1489
02:42:39,120 --> 02:42:48,059
data from the academy ASPEN malnutrition criteria 
and validation study to be able to say anything  

1490
02:42:48,060 --> 02:42:55,800
about advocating for higher staffing levels. 
However, I just say keep posted we certainly  

1491
02:42:55,800 --> 02:43:03,420
plan to make some recommendations about staffing 
levels that might improve patient outcomes, and  

1492
02:43:03,420 --> 02:43:10,319
so, look for that in the literature in 
the coming year maybe is an optimistic  

1493
02:43:11,880 --> 02:43:17,120
expectation, but we certainly are bringing in 
that data and working currently on analyzing it.

1494
02:43:17,120 --> 02:43:23,280
DR. KELLY TAPPENDEN: OK, very good. Thank 
you. And Marcia Schofield,  

1495
02:43:24,180 --> 02:43:29,939
what advice can you provide to payers 
who are...providers, pardon me,  

1496
02:43:29,939 --> 02:43:36,839
who are very afraid of payers denials 
regarding the diagnosis of malnutrition?

1497
02:43:36,840 --> 02:43:44,160
DR. MARCIA SCHOFIELD: Thank you, Kelly. Yeah, I 
understand anxiety audit is real. And out there,  

1498
02:43:44,160 --> 02:43:52,319
especially after the OIG report, the best advice 
that I can give, and this is actually advice from  

1499
02:43:52,319 --> 02:43:58,139
a consortium of organizations that have been 
working on this issue, Academy of Nutrition  

1500
02:43:58,140 --> 02:44:04,380
and Dietetics, ASPEN, American Society of 
Nutrition, and the Clinical Documentation  

1501
02:44:04,380 --> 02:44:10,920
and Integrity Specialists, is some of it comes 
down to good documentation. You know, that you  

1502
02:44:11,700 --> 02:44:16,859
when a physician makes a diagnosis of 
malnutrition, that the medical record  

1503
02:44:16,859 --> 02:44:22,439
supports that diagnosis. And also, as 
I mentioned during my presentation,  

1504
02:44:22,439 --> 02:44:31,139
that there's a plan of care in place. It should 
not add the complication or comorbidity to the  

1505
02:44:31,140 --> 02:44:38,100
hospital billing for malnutrition in any form if 
there isn't a plan of care associated with it. So,  

1506
02:44:38,100 --> 02:44:43,680
evidence-based practice combined with solid 
documentation to support what you're doing  

1507
02:44:44,819 --> 02:44:48,479
and the plan of care to go along 
with it, I think those are key.

1508
02:44:48,479 --> 02:44:56,160
DR. KELLY TAPPENDEN: And we had one of our audience members 
ask about whether or not there was a preference  

1509
02:44:56,160 --> 02:45:05,639
for the GLIM or the Academy ASPEN criteria 
for recognition of malnutrition. What they  

1510
02:45:05,640 --> 02:45:11,700
said was that Blue Cross Blue Shield prefers GLIM 
in their experience, but can you comment on that?

1511
02:45:11,700 --> 02:45:21,240
DR. MARCIA SCHOFIELD: Sure. It's so inconsistent out 
there and it's not always clear. As professional  

1512
02:45:21,240 --> 02:45:27,599
associations who look at the evidence, we don't 
recommend one set of criteria over another. They  

1513
02:45:27,600 --> 02:45:33,240
both need to be validated as previous speakers 
today have already noted. And I'm sure more will  

1514
02:45:33,240 --> 02:45:43,080
speak to that fact as well. So, I understand from 
a payer standpoint that it can drive your practice  

1515
02:45:43,080 --> 02:45:49,979
along the way and you want to be cognizant of 
what they're looking for. But it still comes  

1516
02:45:49,979 --> 02:45:57,540
down to evidence-based care. And in the absence of 
validation of either set of criteria, I think you  

1517
02:45:57,540 --> 02:46:02,160
just need... I don't have any reason to recommend 
one over the other at this point in time.  

1518
02:46:03,180 --> 02:46:09,540
I can imagine it could be pretty crazy with 
all the payers out there to try to tailor your  

1519
02:46:09,540 --> 02:46:16,800
systems based on what each payer is looking at. 
So, I just suggest doing consistent care pathways  

1520
02:46:16,800 --> 02:46:26,580
based on the best available evidence and document. 
Many people have successfully dealt with audits  

1521
02:46:26,580 --> 02:46:33,140
and claims denials with just good documentation 
and the science to back it where it's available.

1522
02:46:33,140 --> 02:46:40,439
DR. KELLY TAPPENDEN: Very good. We have another member 
who has asked about the usefulness of the  

1523
02:46:40,439 --> 02:46:44,700
global malnutrition composite score. 
Can any of you comment on that?

1524
02:46:45,920 --> 02:46:52,920
DR. KENNETH NEPPLE: Yeah, this is Ken. I could comment on that. 
Our institution was kind of the validation site  

1525
02:46:52,920 --> 02:46:57,899
for the Electronic Clinical Quality Measures. 
And so I think it's still yet to be seen  

1526
02:46:58,620 --> 02:47:02,880
how that will be used in different practices 
across different places. But I know one of  

1527
02:47:02,880 --> 02:47:08,460
the lessons that we learned was the more you 
can try to automate that process ,where the  

1528
02:47:08,460 --> 02:47:15,720
dietitian starting from the nursing screening is 
clearly seen by the dieticians' group to be able  

1529
02:47:15,720 --> 02:47:21,840
to say who's seen sooner or later. And then a 
really important part was when the dieticians  

1530
02:47:21,840 --> 02:47:28,440
do their documentation is that clinically evident 
to the provider group, and specifically what those  

1531
02:47:29,580 --> 02:47:35,939
electronic measures are gonna be based around is 
being able to have workflow within the electronic  

1532
02:47:35,939 --> 02:47:41,219
health record where you can pull out that 
data. And so we're kind of in the process of  

1533
02:47:41,220 --> 02:47:48,000
expanding on some of the work we did previously to 
operationalize that. But I think what it does open  

1534
02:47:48,000 --> 02:47:54,600
up is a lot of conversations with our quality 
and safety group about what they're currently  

1535
02:47:54,600 --> 02:48:03,060
reporting and comparing the pros and cons of 
changing to...including that new composite measure. 

1536
02:48:03,960 --> 02:48:07,200
And I would just add one 
comment on the prior question.  

1537
02:48:08,220 --> 02:48:14,160
Because I also at the institutional level 
respond to denials partly because it upset  

1538
02:48:14,160 --> 02:48:20,939
me to see people from the insurance side not 
accurately evaluate this patients. And so  

1539
02:48:21,720 --> 02:48:27,899
I think it's really apparent that there's a very 
broad spectrum of reasons for denial. Some of  

1540
02:48:27,899 --> 02:48:33,839
those are valid, some of those are completely 
invalid. What we did institutionally was to  

1541
02:48:34,620 --> 02:48:42,540
base our documentation primarily off the consensus 
statement from the Academy and ASPEN. But then when  

1542
02:48:42,540 --> 02:48:49,080
we started to see more denials related to GLIM, 
we also supplement with documentation that says  

1543
02:48:49,080 --> 02:48:55,500
this patient also meets GLIM criteria. I think 
the insurance companies have noticed that GLIM  

1544
02:48:55,500 --> 02:49:02,040
is more stringent and that's potentially 
to their benefit. And so in the lack of  

1545
02:49:02,040 --> 02:49:09,060
clinical validation, I think they look at 
financial validation as choosing a definition.

1546
02:49:10,640 --> 02:49:17,880
DR. KELLY TAPPENDEN: Thank you. We also have a question 
from an OT who works with patients with  

1547
02:49:17,880 --> 02:49:25,260
diabetes and cancer and is also a Ph.D. student 
focused on lifestyle medicine. So, they want  

1548
02:49:25,260 --> 02:49:32,340
to ask Dr. Grega and Nepple two questions. How 
can a person like themselves do more to increase  

1549
02:49:32,340 --> 02:49:38,819
health outcomes for their patients receiving OT, 
PT, or speech with regard to providing nutrition  

1550
02:49:38,819 --> 02:49:44,519
education when they don't have a diagnostic 
code on malnutrition? And then secondly,  

1551
02:49:44,520 --> 02:49:49,440
as a Ph.D. student, how do you recommend they 
get more involved with research in this area?

1552
02:49:50,939 --> 02:49:57,299
DR. MEAGAN GREGA: I'll jump in first and then see what 
Dr. Nepple has to add to that. And I would say,  

1553
02:49:57,300 --> 02:50:02,640
well, a couple things. It depends on, like 
where you are, what's your work situation. So,  

1554
02:50:02,640 --> 02:50:08,340
do you have colleagues that you can refer the 
person to? Is there somebody else who should be  

1555
02:50:08,340 --> 02:50:13,500
kind of evaluating whether this person has issues 
with malnutrition? And a lot of what we see is  

1556
02:50:13,500 --> 02:50:19,319
really kind of like, overcaloric 
but undernutrient nutrition in a lot of our  

1557
02:50:19,319 --> 02:50:24,660
patients. And is there a way that you can kind of 
bring this person to the attention of that other  

1558
02:50:24,660 --> 02:50:31,019
colleague in your system who may be able to do the 
actual diagnosis code and the billing? But if not,  

1559
02:50:31,020 --> 02:50:35,880
one of the things that I love to talk about with 
my lifestyle medicine family docs and internal  

1560
02:50:35,880 --> 02:50:40,319
medicine docs, and say, like, how can we 
do this as part of our regular care is I  

1561
02:50:40,319 --> 02:50:45,420
love to give patients homework. So, if you're 
working with them, and as a PT or as an OT,  

1562
02:50:45,420 --> 02:50:51,720
and you're doing your type of service, but you can 
also have some time to talk to them about like,  

1563
02:50:51,720 --> 02:50:55,800
"Hey, have you ever read the book Blue Zones?" 
You know, "Have you ever thought about watching,  

1564
02:50:55,800 --> 02:51:00,359
you know, this documentary?" One of the ones 
that I love to recommend is called PlantWise. 

1565
02:51:00,359 --> 02:51:07,080
It's for free from AdventHealth. It's something 
that you can Google it and you can have patients  

1566
02:51:07,080 --> 02:51:12,000
watch it for free. And say, "Hey, just see what 
you think. Look at it, maybe talk to your provider  

1567
02:51:12,000 --> 02:51:15,660
about it." The other thing, if you become a member 
of the American College of Lifestyle Medicine,  

1568
02:51:15,660 --> 02:51:20,700
which maybe you already are, we have a ton 
of handouts and I know that the dietetic  

1569
02:51:20,700 --> 02:51:26,460
associations do as well that you can give to 
patients. You just have to be thinking about  

1570
02:51:26,460 --> 02:51:31,140
like what other care providers in this patient's 
care should be involved with the education that  

1571
02:51:31,140 --> 02:51:35,760
you're providing. And as far as research with 
the American College of Lifestyle Medicine,  

1572
02:51:35,760 --> 02:51:41,460
we have a lifestyle medicine economic 
research consortium that is trying to  

1573
02:51:42,420 --> 02:51:46,260
support and also get people more involved 
in research and lifestyle medicine. So,  

1574
02:51:46,260 --> 02:51:50,340
that would be a place that I would look. But 
also if you're part of an academic health  

1575
02:51:50,340 --> 02:51:55,080
center or if you've got a college or university 
in your area, that's another place where I see  

1576
02:51:55,080 --> 02:51:59,519
a lot of lifestyle medicine, nutrition 
type medicine, fit our food as medicine  

1577
02:51:59,520 --> 02:52:03,359
projects that are being launched.
Dr. Nepple, what do you think?

1578
02:52:03,359 --> 02:52:10,439
DR. KENNETH NEPPLE: That's a really good answer. I think 
one thing that kind of popped up to my head,  

1579
02:52:11,520 --> 02:52:18,000
it's hard to tell physicians that they don't know 
much about something. And for a lot of physicians,  

1580
02:52:18,000 --> 02:52:22,979
you know, I think it's a challenge because 
we're not really familiar with the criteria for  

1581
02:52:22,979 --> 02:52:28,979
malnutrition or in the definition, but I think 
specifically as an occupational therapist I've  

1582
02:52:28,979 --> 02:52:34,799
learned from our dietitians kind of the focused 
exam, what do you see as far as areas of different  

1583
02:52:34,800 --> 02:52:42,540
muscle wasting? And as an OT or a PT, you're 
going to have some insight into muscle weakness.  

1584
02:52:43,200 --> 02:52:48,599
And I think as you spend time with the patient, 
a straightforward question is to ask if they've  

1585
02:52:48,600 --> 02:52:54,060
lost a lot of weight. And so I think relatively 
quickly you could develop yourself into sort of  

1586
02:52:54,060 --> 02:52:59,640
an expert where beyond just doing the 
usual stuff if you're noticing that a  

1587
02:52:59,640 --> 02:53:04,440
patient has significant muscle wasting and 
they have weakness and they've lost weight,  

1588
02:53:05,399 --> 02:53:10,080
we may be so busy as a clinical service 
managing medications and getting X-rays  

1589
02:53:10,080 --> 02:53:15,779
and doing surgeries that it may not be on 
our radar that this patient has something  

1590
02:53:15,779 --> 02:53:23,160
that could benefit from nutritional consultation.
And I think as a provider if you end up becoming  

1591
02:53:23,160 --> 02:53:26,880
familiar with some of these teams, you know, 
not telling someone they need to get a nutrition  

1592
02:53:26,880 --> 02:53:31,200
consult, but say, "Hey, I saw this patient. I 
noticed they're a lot weaker than I would expect,  

1593
02:53:31,200 --> 02:53:36,720
they have this muscle loss, they've lost 
this weight. I was just wondering if these  

1594
02:53:36,720 --> 02:53:41,399
things are on your radar and if it might be 
beneficial for them to meet with a dietitian." So,  

1595
02:53:41,399 --> 02:53:45,960
I think that sort of approach is helpful and 
you can really become an expert because you're  

1596
02:53:45,960 --> 02:53:52,020
already face to face with the patient maybe more 
than any of the physicians actually end up being.  

1597
02:53:53,160 --> 02:53:57,479
And I think similarly, on the research standpoint, 
it's just reaching out and finding groups that  

1598
02:53:57,479 --> 02:54:02,639
are looking at different questions. And I 
think there's always a benefit of having  

1599
02:54:02,640 --> 02:54:07,741
different insight when you're trying to do 
interdisciplinary or multidisciplinary research.

1600
02:54:08,479 --> 02:54:16,379
DR. KELLY TAPPENDEN: OK. I want to carry on those slots 
by asking you, Marcia a question from Melissa  

1601
02:54:16,380 --> 02:54:24,240
(INAUDIBLE) at Ohio State Medical Center, and that 
is if a malnutrition diagnosis is not provided,  

1602
02:54:24,240 --> 02:54:31,679
no plan of care is proposed, is that something 
other disciplines OT, PT, speech can recommend  

1603
02:54:31,680 --> 02:54:38,399
so that their patients can get the best 
care, or will this be a problem in auditing?

1604
02:54:38,399 --> 02:54:43,259
DR. MARCIA SCHOFIELD: Yeah. Thank you, Kelly. 
And I think I'll build on the two previous  

1605
02:54:43,260 --> 02:54:51,000
responses as well. Certainly a couple points I 
want to make. Team-based care is very important.  

1606
02:54:51,000 --> 02:54:57,960
And I think in the end of the day, having the team 
of professionals working with the physicians and  

1607
02:54:57,960 --> 02:55:04,080
everybody else and the patient to come up with 
a plan of care assessment, all of that thing,  

1608
02:55:04,080 --> 02:55:09,240
everybody can play a role. There's also a 
difference that I think sometimes gets lost  

1609
02:55:09,240 --> 02:55:20,399
between doing screening versus assessment. I 
think any members of the healthcare team can  

1610
02:55:20,399 --> 02:55:27,540
look at screening for risk of malnutrition. So, 
many of the things that Dr. Nepple had mentioned,  

1611
02:55:27,540 --> 02:55:34,319
you know, anybody can do that screening. The 
assessment piece, though, where you actually  

1612
02:55:34,319 --> 02:55:41,580
get into what is somebody's nutritional 
status. Are they actually malnourished,  

1613
02:55:41,580 --> 02:55:47,580
of what type? And what's the appropriate treatment 
and intervention? There, you start getting into  

1614
02:55:47,580 --> 02:55:54,540
scope of practice and legal aspects of what 
somebody can legally do within a specific state  

1615
02:55:54,540 --> 02:56:02,700
based on licensure requirements, for instance, or 
once again just your education and credentialing. 

1616
02:56:02,700 --> 02:56:09,300
So, physicians can certainly do nutrition 
assessment and come up with plans of care.  

1617
02:56:09,300 --> 02:56:16,740
Registered dietician nutritionists, that's within 
their scope of practice to do those things. Yes,  

1618
02:56:17,340 --> 02:56:25,800
OT and PT have components of the consensus 
statement things they can do like handgrip  

1619
02:56:25,800 --> 02:56:32,760
strength type of thing, just that functional 
capacity. But I would say if you're talking  

1620
02:56:32,760 --> 02:56:39,060
about actually making a diagnosis of malnutrition 
and coming up with an appropriate care plan,  

1621
02:56:40,200 --> 02:56:46,139
I think you definitely have to be careful 
because you could be violating licensure  

1622
02:56:46,140 --> 02:56:51,840
laws for both physicians and registered 
dietitian nutritionists if others move  

1623
02:56:51,840 --> 02:56:56,479
beyond nutrition screening into 
the assessment side of things.

1624
02:56:56,479 --> 02:57:03,719
DR. KELLY TAPPENDEN: So, is it OK for the RD or 
RDN to pull that information from the  

1625
02:57:03,720 --> 02:57:07,362
OT/PT assessment like handgrip 
strength, gait speed, sit-stand?

1626
02:57:07,362 --> 02:57:11,580
DR. MARCIA SCHOFIELD: Absolutely, absolutely. You 
know, different people are doing different  

1627
02:57:11,580 --> 02:57:17,399
things. Dr. Nepple talked about the nutrition 
focus physical exam, which the dietitians are  

1628
02:57:17,399 --> 02:57:25,620
trained to do. That's where in this world where 
we want to be careful that we're not providing  

1629
02:57:26,580 --> 02:57:31,859
duplicate care, right, that becomes costly 
for the system. And even for patients going  

1630
02:57:31,859 --> 02:57:37,500
through why do I have to have the same tests 
done multiple times, we certainly can draw on  

1631
02:57:38,399 --> 02:57:43,559
the expertise of everybody on the team and 
the assessments that they've done. And I  

1632
02:57:43,560 --> 02:57:47,701
think that helps the physician 
ultimately make the diagnosis.

1633
02:57:48,800 --> 02:57:58,680
DR. KELLY TAPPENDEN: OK, very good. So, when we think about things like 
the global malnutrition composite score, are we  

1634
02:57:58,680 --> 02:58:05,100
to the point where we have these scores validated 
to predict response to a nutrition intervention?  

1635
02:58:06,300 --> 02:58:11,819
We have lots of data showing that nutrition 
interventions matter, right? And when I think  

1636
02:58:11,819 --> 02:58:18,540
in critical care, there's some data showing 
that certain patients with a high malnutrition  

1637
02:58:18,540 --> 02:58:23,279
score will respond to intervention. 
But what about in other disease states?

1638
02:58:25,859 --> 02:58:31,920
DR. KENNETH NEPPLE: Based on the silence,  

1639
02:58:31,920 --> 02:58:41,460
I guess I'll take that one. The way I think about 
that composite score, it's really an institutional  

1640
02:58:42,060 --> 02:58:49,319
assessment. And I think to some extent, it shows 
how much is malnutrition assessment on the radar  

1641
02:58:49,319 --> 02:58:56,340
at the institutional level. When we looked 
at the prevalence of malnutrition diagnoses,  

1642
02:58:56,340 --> 02:59:02,819
one of the things we did in that study, because we 
had access to star ratings of different hospitals,  

1643
02:59:02,819 --> 02:59:08,939
we looked and said, were higher quality, you 
know, supposedly higher quality hospitals  

1644
02:59:08,939 --> 02:59:14,339
with more stars, did they do a better job 
of assessing malnutrition? And we found a  

1645
02:59:14,340 --> 02:59:19,260
statistically significant relationship there. 
I think there's some caution that that's not  

1646
02:59:19,260 --> 02:59:25,680
necessarily a cause and effect, but that's an 
association where these types of things that may  

1647
02:59:25,680 --> 02:59:30,479
not be as recognized by all institutions, if your 
institution is doing a good job of recognizing,  

1648
02:59:30,479 --> 02:59:35,099
then it may mean that they're doing a lot of 
good things in lots of other spaces too and  

1649
02:59:35,100 --> 02:59:39,420
it may even mean that you have resources to 
be able to look into these different spaces. 

1650
02:59:41,340 --> 02:59:47,700
I think from an outcome measure, the randomized 
controlled trials of immunonutrition  

1651
02:59:49,439 --> 02:59:53,700
clearly show that at the patient level, 
if you're identifying in managing,  

1652
02:59:54,960 --> 02:59:59,279
supplementing that there's benefit, I 
think there is some question in those  

1653
02:59:59,279 --> 03:00:02,819
types of studies, do you even need to screen 
if everybody needs the same type of treatment?  

1654
03:00:03,840 --> 03:00:09,720
But I think there's definitely a gap 
in looking at patient-level outcomes.  

1655
03:00:10,560 --> 03:00:17,040
But for me, institutional support leads to 
paradigms that even though there may not be direct  

1656
03:00:17,040 --> 03:00:23,100
evidence, it makes sense. For example, in our 
cancer center, we used to not have a dietician.  

1657
03:00:23,100 --> 03:00:28,439
And so I remember hearing someone getting sent 
to the local grocery store as an option because  

1658
03:00:28,439 --> 03:00:35,519
there was no dietitian available. As we built up 
support, now there's a dedicated dietitian. So,  

1659
03:00:35,520 --> 03:00:40,560
there's someone who's available for those 
consultations. And if you're discharging someone,  

1660
03:00:40,560 --> 03:00:47,340
you can plan to have them see a dietitian as in 
follow-up. And you can see how it's not a far  

1661
03:00:47,340 --> 03:00:55,319
jump from no nutritional counseling to appropriate 
counseling by a specialist has got to be better and at  

1662
03:00:55,319 --> 03:01:02,399
least is a better patient experience.
I think ideally we would have data on  

1663
03:01:02,399 --> 03:01:07,920
decreasing readmissions and those types of 
things. But it's just a little bit more,  

1664
03:01:08,819 --> 03:01:13,679
you know, it's very difficult to evaluate that 
when you're not sort of in a situation where you  

1665
03:01:13,680 --> 03:01:20,280
can randomize versus if you had drug one versus 
drug two, that's a much easier situation to study.

1666
03:01:21,500 --> 03:01:29,340
DR. KELLY TAPPENDEN: Right. So, my understanding is that as 
part of a QI initiative, the score at this point,  

1667
03:01:29,340 --> 03:01:34,260
the Global Malnutrition Composite Score, really 
looks at whether or not steps have been done,  

1668
03:01:34,260 --> 03:01:40,140
right? It's a process as opposed to being able to 
have measured outcomes at this point. So, another  

1669
03:01:40,140 --> 03:01:44,460
important area of research, I think we have a 
lot of things where we're recommending processes,  

1670
03:01:45,300 --> 03:01:53,700
but we need to have now those data substantiating 
with outcomes. Another question then from our  

1671
03:01:53,700 --> 03:02:00,599
audience is, if one of you could talk about the 
importance of albumin...the albumin globulin ratio  

1672
03:02:00,600 --> 03:02:07,680
for determining malnutrition over albumin alone, 
and is that ratio checked in healthy outpatients?

1673
03:02:07,680 --> 03:02:20,340
DR. MEAGAN GREGA: I think I would defer that to some of the 
dietitians in our group here. Dr. Hand.

1674
03:02:22,640 --> 03:02:28,620
DR. ROSA HAND: So, I'm not totally familiar with this. 
I think, Kelly, if you wanted to take a stab,  

1675
03:02:28,620 --> 03:02:32,519
that would be great. But I think I can 
fairly confidently say that this is not  

1676
03:02:32,520 --> 03:02:39,780
commonly checked in healthy outpatients. I can't 
speak to the value in hospitalized patients.

1677
03:02:42,060 --> 03:02:46,201
DR. KELLY TAPPENDEN: I would have to agree I'm not 
familiar with it being commonly used.  

1678
03:02:47,819 --> 03:02:50,279
Are there any inpatient comments on this?

1679
03:02:50,279 --> 03:02:57,479
DR. KENNETH NEPPLE: On the physician side of 
things, you know, checking albumin in  

1680
03:02:57,479 --> 03:03:01,979
laboratory analysis was part of what we had 
done previously. But I remember the first  

1681
03:03:01,979 --> 03:03:06,359
big meeting we had with our dieticians and 
when we reviewed that consensus statement,  

1682
03:03:06,359 --> 03:03:11,279
that, you know, thought is that laboratory 
measures are not as accurate. So, we're not,  

1683
03:03:12,420 --> 03:03:17,399
even in the consensus statement or GLIM, 
laboratory assessments are not part of that. So,  

1684
03:03:17,399 --> 03:03:24,059
we have not been using laboratory assessments. 
However, I think that's an area if someone in  

1685
03:03:24,060 --> 03:03:28,859
the future were to validate that, there may be 
benefit. But it's not part of our practice here.

1686
03:03:28,859 --> 03:03:36,779
DR. KELLY TAPPENDEN: OK, very good. One final question then 
before we break. And it's just sort of a nuts  

1687
03:03:36,779 --> 03:03:44,219
and bolts question, Dr. Nepple, for you. And that 
is what are the steps that you went through with  

1688
03:03:44,220 --> 03:03:51,720
your technology-enabled workflow? You know, who 
do people talk to to get such efficiencies built  

1689
03:03:51,720 --> 03:03:57,180
into their systems at their hospital? What's 
your recommendations there of the how-to?

1690
03:03:57,180 --> 03:04:04,560
DR. KENNETH NEPPLE: Sure. I've got a 40-minute version 
of how to do that, but I'll do the 40-second one. I  

1691
03:04:04,560 --> 03:04:10,979
think it's a couple of things. It's just getting 
everybody in a room, including the informatics  

1692
03:04:10,979 --> 03:04:16,559
folks. And I think the one thing I've really kind 
of learned over time, because I work a lot with  

1693
03:04:16,560 --> 03:04:21,720
our informatics group, too, is they want to know 
that somebody else has already done something and  

1694
03:04:21,720 --> 03:04:26,580
that you're not inventing something that is 
not going to bring value or is really hard to  

1695
03:04:26,580 --> 03:04:33,300
operationalize. And so now I think there's enough 
examples out there of how to do this workflow  

1696
03:04:34,319 --> 03:04:40,500
that it's really just a matter of getting the 
right people together. And we've provided a few  

1697
03:04:40,500 --> 03:04:47,580
resources in the past about how to operationalize 
within EPIC or other electronic health records.  

1698
03:04:48,479 --> 03:04:57,959
But it's...for us the big push was also having 
the quality and safety people at that group in  

1699
03:04:57,960 --> 03:05:04,200
the hospital finance group too. Because we 
could have developed a really good workflow,  

1700
03:05:04,859 --> 03:05:09,839
but we really didn't know how beneficial it was as 
far as driving other things within the hospital,  

1701
03:05:09,840 --> 03:05:14,939
improving quality metrics because of risk 
adjustment, or improving hospital reimbursement. 

1702
03:05:14,939 --> 03:05:19,679
So, having those people in the 
room once the pilot was successful,  

1703
03:05:20,640 --> 03:05:26,220
very quickly, hospital leadership was asking, you 
know, how do we make this the workflow for all  

1704
03:05:26,220 --> 03:05:31,740
places? And moving into the pediatric population 
and other things like that. So, I think it's  

1705
03:05:31,740 --> 03:05:36,240
really starting with the right people in the room 
and then telling people that this is not a super  

1706
03:05:37,380 --> 03:05:43,740
hard heavy game that's going to require years and 
years of work. It is really just figuring out  

1707
03:05:44,340 --> 03:05:51,180
what are some discrete things that you can do to 
improve communication via people understanding  

1708
03:05:51,180 --> 03:05:56,479
what other groups are doing, and then documenting 
that as discrete data within the record.

1709
03:05:56,479 --> 03:06:01,080
DR. KELLY TAPPENDEN: Very good. Now, Dr. Hand, 
is there anything from the RD  

1710
03:06:01,080 --> 03:06:04,500
workflow perspective that you 
would specifically add to that?

1711
03:06:04,500 --> 03:06:10,920
DR. ROSA HAND: That's a great question, Kelly. I 
think that the data that we have on dietitian  

1712
03:06:10,920 --> 03:06:18,540
staffing to this point is nowhere near that 
granular. So, we have information about  

1713
03:06:20,100 --> 03:06:24,899
how frequently patients are receiving 
assessments versus reassessments,  

1714
03:06:24,899 --> 03:06:30,299
or are they receiving just one encounter or 
multiple during the hospital stay? And we  

1715
03:06:30,300 --> 03:06:36,120
have information about how frequently they're 
receiving interventions, including nutrition  

1716
03:06:36,120 --> 03:06:42,180
education. But in terms of the workflow, I 
think very often that's too individualized  

1717
03:06:42,180 --> 03:06:49,560
by hospital for us to easily collect data on it. 
So, that is potentially another area of research  

1718
03:06:49,560 --> 03:06:56,880
opportunity is, you know, a standardized way 
of setting up this workflow for dietitians.

1719
03:06:56,880 --> 03:07:03,720
DR. KELLY TAPPENDEN: OK, very good. Now, in reference 
to my very first question to Dr. Grega  

1720
03:07:03,720 --> 03:07:07,620
about the excellent call to action 
with specific things that we can do,  

1721
03:07:07,620 --> 03:07:14,700
I'm told that the Academy website has an action 
alert that any of us can go and receive specific  

1722
03:07:15,540 --> 03:07:19,680
guidance regarding that. And that's not 
just providers of different disciplines,  

1723
03:07:19,680 --> 03:07:25,680
but patients also. So, with that, I want to thank 
each of you for your excellent presentations,  

1724
03:07:26,460 --> 03:07:30,720
the audience for their engagement and 
questions. And now we'll take a quick  

1725
03:07:30,720 --> 03:07:37,183
break before joining Dr. Seres for Session 2, 
which will begin at 3:40pm Eastern. Thank you.

1726
03:07:37,183 --> 03:07:42,479
DR. DAVID SERES: Welcome to session two entitled 
"Moving Beyond the Terminology of Malnutrition." 

1727
03:07:42,479 --> 03:07:48,240
I'm Dr. David Seres, and it's my honor to be 
your moderator for this session. I'm Professor  

1728
03:07:48,240 --> 03:07:53,639
of Medicine in the Institute of Human Nutrition, 
Director of Medical Nutrition, and associate  

1729
03:07:53,640 --> 03:08:00,000
Clinical Ethicist at Columbia University Irving 
Medical Center in New York City. Just as an aside,  

1730
03:08:00,000 --> 03:08:05,819
you'll note that our oral introductions to our 
illustrious speakers is brief, their CVs are long,  

1731
03:08:05,819 --> 03:08:10,679
but this is to maximize the time for the 
presentation. So I call your attention to  

1732
03:08:10,680 --> 03:08:15,300
the presenters' button, the button for which is 
in the controls on the left side of your screen.  

1733
03:08:16,260 --> 03:08:21,420
Brief titles for the speakers appear if you open 
that window up, but there's a link to a more  

1734
03:08:21,420 --> 03:08:26,460
complete bio for each. Also, the controls for the 
media player which will show you the live videos  

1735
03:08:26,460 --> 03:08:35,040
of the presenters during the Q&A session is in 
that same section. This session, which is titled  

1736
03:08:35,819 --> 03:08:42,299
'Malnutrition in Clinical Disease: Moving Towards 
Developing a Unified Definition of Malnutrition'. 

1737
03:08:42,899 --> 03:08:47,460
In it, we'll be addressing what I think 
is the fundamental question currently  

1738
03:08:47,460 --> 03:08:52,439
surrounding our approach to malnutrition and the 
credibility of what we do every day, and that is,  

1739
03:08:52,439 --> 03:08:58,679
what is it that we're really describing when we 
call things malnutrition? For this afternoon,  

1740
03:08:59,700 --> 03:09:04,200
we have several speakers and then we 
have a couple...we have several more tomorrow.  

1741
03:09:04,979 --> 03:09:09,779
Charlene Compher will be speaking about the 
current methods for diagnosing malnutrition.  

1742
03:09:09,779 --> 03:09:15,540
I'll be giving a talk about how nutrition... 
malnutrition as it's currently defined 

1743
03:09:15,540 --> 03:09:21,899
is actually a marker for disease severity. Phil 
Schuetz from Switzerland is going to be talking  

1744
03:09:21,899 --> 03:09:29,879
about the results of some of his work in the 
effort trial, which Dr. Jensen alluded to, and  

1745
03:09:29,880 --> 03:09:36,540
talking about inflammation and how its interplays 
with the diagnosis. Patrick Stover is going to be  

1746
03:09:36,540 --> 03:09:44,640
talking to us about the consequences and treatment 
of micronutrient deficiencies. Katherine Tucker  

1747
03:09:44,640 --> 03:09:53,400
will be talking about nutritionally vulnerable and 
hidden hunger, tying on to some of what Nancy,  

1748
03:09:54,240 --> 03:10:00,479
from the Partnership for a Healthier 
America, talked to us about earlier today. 

1749
03:10:01,740 --> 03:10:04,139
And then we'll go to a Q&A session,  

1750
03:10:05,040 --> 03:10:10,560
and then tomorrow we'll be talking about 
things like body composition and different  

1751
03:10:10,560 --> 03:10:16,080
disease-specific cachexia states. 
So, on that note, let's get started.

1752
03:10:16,080 --> 03:10:29,100
DR. CHARLENE COMPHER: Hello, I'm delighted to be with you today 
to talk about updating what we know about  

1753
03:10:29,100 --> 03:10:34,860
malnutrition in adults in clinical settings, and 
to project what we need to know in the future.  

1754
03:10:35,819 --> 03:10:41,340
What is the Global Leadership Initiative on 
Malnutrition? This is the, an approach to  

1755
03:10:41,340 --> 03:10:46,680
diagnosing malnutrition that resulted from an 
ongoing collaboration among recognized global  

1756
03:10:46,680 --> 03:10:52,200
leaders in the field of nutrition support. 
One goal was to enable busy clinicians with  

1757
03:10:52,200 --> 03:10:58,559
limited nutrition knowledge to make at least 
a preliminary diagnosis and possibly refer  

1758
03:10:58,560 --> 03:11:04,319
to experts for appropriate intervention. A
second goal was to provide a framework under  

1759
03:11:04,319 --> 03:11:12,240
which existing approaches could be placed. 
And finally, we needed to develop standardized  

1760
03:11:12,240 --> 03:11:18,840
language so that we can identify best practices 
in response to treatment of malnutrition.  

1761
03:11:18,840 --> 03:11:27,960
We realized in our initial discussions in 2017 
that all of the existing screening and diagnostic  

1762
03:11:27,960 --> 03:11:37,380
tools for malnutrition used the same variables 
as you can see on this slide. So we set up the  

1763
03:11:37,380 --> 03:11:44,100
GLIM approach, which is...depends on screening for 
malnutrition using a validated screening tool,  

1764
03:11:44,100 --> 03:11:53,040
and then considering phenotypic criteria that are 
common in all of the nutrition assessment programs  

1765
03:11:53,040 --> 03:12:00,000
and etiologic criteria of either reduced food 
intake or disease burden/inflammatory condition. 

1766
03:12:00,000 --> 03:12:07,500
If they have one phenotypic and one etiologic, 
then they meet the criteria. But then we need  

1767
03:12:07,500 --> 03:12:14,340
to grade the severity of malnutrition. The two 
approaches that are most common in the U.S. today  

1768
03:12:14,340 --> 03:12:21,899
are GLIM and AAIM, the Academy of Nutrition and 
Dietetics and Aspen Indicators for Malnutrition.  

1769
03:12:21,899 --> 03:12:30,000
As you can see from this slide, the weight loss 
criteria and the reduced muscle mass criteria are  

1770
03:12:30,000 --> 03:12:39,359
very, very similar in the two approaches. However, 
AAIM does not include a BMI category. And the  

1771
03:12:39,359 --> 03:12:47,580
reason is that we know that malnutrition can exist 
regardless of BMI level. It's entirely possible  

1772
03:12:47,580 --> 03:12:56,760
that the BMI categories in GLIM will disappear 
with further research. We looked at the construct  

1773
03:12:56,760 --> 03:13:04,319
and concurrent criterion validity when GLIM was 
compared with SGA, which is viewed as a semi-gold  

1774
03:13:04,319 --> 03:13:12,779
standard in our prospective observational cohorts. 
If you look in the black...first black box,  

1775
03:13:12,779 --> 03:13:23,460
you will see the percentage of malnutrition with 
GLIM goes from about 30% to about 80%, depending  

1776
03:13:23,460 --> 03:13:29,220
on the clinical context. And we want to see this.
We want to see that we don't get the same  

1777
03:13:29,220 --> 03:13:34,620
prevalence of malnutrition in every group 
that we examined. And the box on the right,  

1778
03:13:34,620 --> 03:13:42,720
shows you the strong sensitivity and specificity 
of the approach. Very similar data were  

1779
03:13:42,720 --> 03:13:50,460
also found when the the AAIM approach was compared 
to SGA. We also wanted to look at predictive  

1780
03:13:50,460 --> 03:13:58,979
validity. And these are based on... When patients 
are identified with malnutrition. In published  

1781
03:13:58,979 --> 03:14:06,839
reports, the left figure shows hospital mortality 
was increased 1.3-to-2.5 fold, depending on,  

1782
03:14:06,840 --> 03:14:14,040
once again on the clinical context. And the right 
figure shows 30-day readmissions are increased.  

1783
03:14:14,640 --> 03:14:23,040
Well, if we diagnose malnutrition, now, what can 
we do? If the patient has normal GI functions,  

1784
03:14:23,040 --> 03:14:29,160
some version of increasing nutrient intake 
using food or oral nutrition supplements  

1785
03:14:29,160 --> 03:14:35,460
or tube feeds could be considered. If they do not 
have adequate GI function to support their needs,  

1786
03:14:35,460 --> 03:14:42,420
then parenteral nutrition is an option, 
either in the hospital or at home. Does this  

1787
03:14:42,420 --> 03:14:48,180
work? What do we know about applying medical 
nutrition therapy in malnourished patients? 

1788
03:14:48,180 --> 03:14:53,760
These two randomized controlled trials in 
relatively small samples of European patients  

1789
03:14:53,760 --> 03:15:00,720
demonstrated improved hospital length of stay, 
readmissions, and reduced complications when oral  

1790
03:15:00,720 --> 03:15:09,120
nutrition supplement, snacks, or diet modification 
were applied. This is a larger study that you'll  

1791
03:15:09,120 --> 03:15:17,340
hear more about later, I suspect, by Dr. Schuetz, 
but it shows the impact of...in a sample of 2,000  

1792
03:15:17,340 --> 03:15:23,760
Swiss medical patients who were randomized to 
receive intense efforts to meet their energy  

1793
03:15:23,760 --> 03:15:30,779
and protein goals or standard hospital diet. The 
A panel shows you the composite outcome,  

1794
03:15:30,779 --> 03:15:37,319
which includes mortality, but other variables and 
the B panel is outcome. Both are significantly  

1795
03:15:37,319 --> 03:15:45,299
improved when the...with the intervention. And what 
about when patients are not in the hospital? What  

1796
03:15:45,300 --> 03:15:54,540
about when they're home? These are older adults 
treated with moderate or severe malnutrition, at  

1797
03:15:54,540 --> 03:16:00,960
discharge were given two cans of oral nutritional 
supplement or placebo daily, 90-day mortality was  

1798
03:16:00,960 --> 03:16:08,160
significantly reduced. Well, we know what we 
know, but we don't know what we don't know. 

1799
03:16:10,380 --> 03:16:17,580
If we are able to standardize a core set 
of variables for GLIM, can we count on NIH  

1800
03:16:17,580 --> 03:16:23,580
to fund this area of research? Will clinicians 
embrace their use? Will journal editors permit  

1801
03:16:23,580 --> 03:16:30,359
adequate whitespace to display these data points 
as a strategy to permit comparisons? We've made  

1802
03:16:30,359 --> 03:16:35,880
great progress in the past 15 years at
having BMI be reported in publications,  

1803
03:16:35,880 --> 03:16:42,899
but BMI is not the most sensitive variable to 
identify malnutrition in clinical settings.  

1804
03:16:42,899 --> 03:16:49,080
Will clinical trialists report more granular 
data so that we can understand the impact?  

1805
03:16:49,680 --> 03:16:55,920
Are we actually waiting too late to 
identify malnutrition? We know that  

1806
03:16:55,920 --> 03:17:01,020
there is great risk of loss of lean 
mass early during hospital admission.  

1807
03:17:04,200 --> 03:17:09,960
How important are weight loss and muscle 
mass during a hospital admission? We  

1808
03:17:09,960 --> 03:17:16,380
use them to identify malnutrition when they 
have occurred prior to admission. But is it  

1809
03:17:16,380 --> 03:17:24,720
also meaningful to note the weight loss during 
a hospital admission? Would the...now 

1810
03:17:24,720 --> 03:17:29,760
we're faced with short admissions and we're 
faced with patients with fluid overload, 

1811
03:17:29,760 --> 03:17:33,240
but would the availability 
of portable, affordable,  

1812
03:17:33,240 --> 03:17:39,540
reliable body composition devices bridge this 
gap? What is a nutrition-sensitive outcome?  

1813
03:17:40,439 --> 03:17:45,660
The...most of the outcomes I've shown you to date 
are objective, and they're commonly reported,  

1814
03:17:45,660 --> 03:17:52,260
but they're also driven very strongly by the 
inflammatory process itself. We need to establish  

1815
03:17:52,260 --> 03:17:58,740
nutrition-sensitive outcomes that are less 
impacted by inflammation. Would discharge to home  

1816
03:17:58,740 --> 03:18:04,679
rather than a rehab center or nursing home without 
readmission, would that be meaningful? From a  

1817
03:18:04,680 --> 03:18:10,201
patient's perspective, would measures of fatigue 
or physical function be much more important?  

1818
03:18:12,960 --> 03:18:20,939
Can we identify a blood or urine biomarker panel? 
In clinical practice, we commonly review panels  

1819
03:18:20,939 --> 03:18:26,759
of biomarkers to aid in the diagnosis and 
management of diseases and conditions. We  

1820
03:18:26,760 --> 03:18:36,479
really need this for malnutrition. Can we honestly 
expect a homeostatic nutrition intervention to  

1821
03:18:36,479 --> 03:18:43,740
improve the clinical outcomes from unphysiologic, 
extremely inflammatory challenge? Do we need to  

1822
03:18:43,740 --> 03:18:50,160
study specific groups according to severity of 
illness or inflammation to answer this question? 

1823
03:18:52,140 --> 03:18:59,100
Finally, if providing MNT does not improve 
outcomes in the context of severe inflammation,  

1824
03:18:59,100 --> 03:19:04,439
does it cause harm? We know that 
excessive energy and protein intake  

1825
03:19:04,439 --> 03:19:09,059
in some individuals can worsen outcomes. 
But if harm is not part of the picture,  

1826
03:19:09,899 --> 03:19:18,240
is it still important to feed them, to give 
them a survival advantage for other intensive  

1827
03:19:18,240 --> 03:19:26,880
interventions to improve their mortality rate? 
What is the longer term risk of not feeding them?  

1828
03:19:27,960 --> 03:19:34,020
While I've updated our findings to date on 
malnutrition in clinical settings and the most  

1829
03:19:34,020 --> 03:19:40,800
impactful treatment approaches that have been 
described to date, I recognize that I leave you  

1830
03:19:40,800 --> 03:19:47,100
with more questions than answers. As always, a 
serious consideration of research opens up more  

1831
03:19:47,100 --> 03:19:52,979
questions and answers. Dealing with malnutrition 
in clinical settings is no exception. However,  

1832
03:19:52,979 --> 03:19:58,500
the fact that this workshop is focused on 
identifying research gaps and opportunities  

1833
03:19:58,500 --> 03:20:03,600
is the first step towards answering these 
questions. Thank you for your attention.

1834
03:20:03,600 --> 03:20:10,439
DR. DAVID SERES: Hi, I'm Dr. David Seres. 
On behalf of my colleagues and myself,  

1835
03:20:10,439 --> 03:20:16,319
on the organizing committee, we're really pleased 
that you're attending. Thank you. Malnutrition  

1836
03:20:16,319 --> 03:20:22,559
is a confusing term, and we're hoping that we can 
create a little bit of clarity with this session.  

1837
03:20:24,300 --> 03:20:30,840
Just to disclose, I don't have any commercial 
biases, but I am very opinionated and hopefully  

1838
03:20:30,840 --> 03:20:39,060
stick to the evidence. I have a real concern 
about using observational research. Here's  

1839
03:20:39,060 --> 03:20:46,859
the good example taught to me by my mentor, 
Ronald Koretz. I, every time I get on a plane,  

1840
03:20:46,859 --> 03:20:52,500
go to the pilot and ask that they please not 
turn on the seatbelt sign because there's a  

1841
03:20:52,500 --> 03:20:58,800
100% concordance between turning on the seatbelt 
sign and the ride getting rough. So, of course,  

1842
03:20:58,800 --> 03:21:04,439
that means that the seatbelt sign must 
be causal. And of course, that's silly.  

1843
03:21:04,439 --> 03:21:11,580
But a lot of our practice and science is 
based on that kind of thinking. In fact,  

1844
03:21:11,580 --> 03:21:19,620
a study done at Tufts looked at the concordance 
between the conclusions of observational research  

1845
03:21:19,620 --> 03:21:26,580
and the outcomes of randomized trials in nutrition 
studies and found that there was no concordance. 

1846
03:21:28,500 --> 03:21:33,960
A lot of our definitions of malnutrition and 
malnutrition risk have been well validated,  

1847
03:21:33,960 --> 03:21:40,500
but the problem is how they've been validated. 
If you look just at some recent examples,  

1848
03:21:40,500 --> 03:21:46,800
and these are representative of going back all the 
way through history, that these are all basically  

1849
03:21:47,819 --> 03:21:56,460
validating against each other and against 
outcomes. For instance, the GLIM and PGA predicted  

1850
03:21:56,460 --> 03:22:01,979
outcomes, toxicity, treatment interruptions, use 
of nutrition support, and a decrease in quality  

1851
03:22:01,979 --> 03:22:09,179
of life. But they did not predict whether or not 
the patient responded to the intervention. This is  

1852
03:22:09,180 --> 03:22:17,340
a new malnutrition score, the Graz score, and 
basically, it evaluated itself against another  

1853
03:22:17,340 --> 03:22:26,819
scoring system. And here the SGA is validated as 
being valuable because it correlates well with  

1854
03:22:26,819 --> 03:22:31,799
anthropometric and biochemical parameters. But 
these are all sort of foregone conclusions because  

1855
03:22:31,800 --> 03:22:39,600
so many of these include the phenomena that occur 
as a result of systemic inflammatory disease.  

1856
03:22:43,140 --> 03:22:48,420
The NUTRIC score was proposed as being 
highly predictive of response to nutrition, 

1857
03:22:48,420 --> 03:22:55,200
and the problem with that is the way that this was 
done. The paper, which actually promotes itself  

1858
03:22:55,200 --> 03:23:02,340
as identifying patients who will benefit most 
from nutrition therapy, was based on post-hoc  

1859
03:23:02,340 --> 03:23:08,520
analysis of a randomized trial, which glutamine and 
antioxidant supplements were given, and feeding was  

1860
03:23:08,520 --> 03:23:13,680
given to all patients. And of course, the 
NUTRIC score predicted mortality very well,  

1861
03:23:14,700 --> 03:23:26,880
as have all of these scores. In this same study, 
if you look, the gray area is patient, it's with a  

1862
03:23:26,880 --> 03:23:34,920
low NUTRIC score, and the brown, high NUTRIC score 
that the ones with a high NUTRIC score, and the  

1863
03:23:34,920 --> 03:23:43,979
lowest percentage of calories provided had a very 
strong increase in mortality. But again, these are  

1864
03:23:43,979 --> 03:23:52,859
observational data and are not prospective in 
predicting response to nourishment. They only  

1865
03:23:53,520 --> 03:23:57,600
suggest that sicker people are harder to feed.  

1866
03:23:59,880 --> 03:24:12,720
And again [inaudible] predicts mortality. The predictive value 
of the diagnosis of malnutrition has been studied  

1867
03:24:12,720 --> 03:24:21,060
at our institution. Of note, the diagnosis of 
severe malnutrition significantly increased  

1868
03:24:22,260 --> 03:24:31,920
length of stay and mortality, both length of 
stay in the hospital and the ICU length of stay. 

1869
03:24:31,920 --> 03:24:40,560
Of note is that the effect was much stronger in 
the cardiothoracic ICU. We propose that this is  

1870
03:24:40,560 --> 03:24:47,160
due to the fact that this is a healthier 
population on the, as they come in and  

1871
03:24:47,160 --> 03:24:52,859
if they develop "malnutrition", they have 
been in the hospital for a long time due to  

1872
03:24:52,859 --> 03:24:59,399
more complications, whereas a lot of the other 
ICUs, the admissions are sicker to begin with.  

1873
03:25:01,319 --> 03:25:10,920
We've also looked at whether or not malnutrition 
is predictive in patients with congestive  

1874
03:25:10,920 --> 03:25:17,220
heart failure, and in fact, it's very strongly 
predictive of length of stay adding of medium six  

1875
03:25:17,220 --> 03:25:26,399
days and increasing mortality. It also decreases 
the probability that the patient who's discharged  

1876
03:25:26,399 --> 03:25:35,040
from the hospital and goes home as opposed to a 
facility for rehabilitation or long term care. So,  

1877
03:25:35,040 --> 03:25:42,479
in summary, we've shown that these scoring systems 
that we have for malnutrition and nutrition risk  

1878
03:25:42,479 --> 03:25:51,299
are extremely good at predicting outcomes and 
are without a doubt, good markers for disease  

1879
03:25:51,300 --> 03:25:57,899
severity. However, overall they have failed to 
predict who is going to respond to nourishment. 

1880
03:25:57,899 --> 03:26:06,179
And I would propose that the terms malnutrition 
and malnourished are absolutely not synonymous.  

1881
03:26:06,180 --> 03:26:12,120
Otherwise, these would predict who would 
respond to nourishment and malnourishment  

1882
03:26:12,120 --> 03:26:18,239
should mean that there is some sort of new 
nourishment that could improve outcomes.  

1883
03:26:20,460 --> 03:26:26,700
Research questions that remain are enormous. 
The basic question of what, how much, by what  

1884
03:26:26,700 --> 03:26:34,080
route and when should we feed patients is really 
unanswered in our sick patients. We need to find  

1885
03:26:34,080 --> 03:26:39,899
out if any of our scores do predict the response 
to nutrition interventions. And in fact, there  

1886
03:26:39,899 --> 03:26:48,359
are data that suggest that they don't. It's really 
no surprise because so many of them rely a lot on  

1887
03:26:48,359 --> 03:26:55,139
the presence of inflammation and inflammation, 
Dr. Schuetz, in the next lecture will discuss,  

1888
03:26:55,140 --> 03:27:04,080
actually is a negative predictor for a response 
to nutrition. So, we have to look at what the  

1889
03:27:04,080 --> 03:27:09,960
parameters are that actually identify patients 
who will respond. We also don't know how warm  

1890
03:27:09,960 --> 03:27:17,040
nourishment must be inadequate to be significant 
clinically, and we don't know what is adequate or  

1891
03:27:17,040 --> 03:27:22,680
ideal nourishment for our sick patients.
There are a number of roadblocks to this  

1892
03:27:22,680 --> 03:27:27,960
kind of research. We don't record 
well how much patients are eating prior  

1893
03:27:27,960 --> 03:27:33,540
to admission. It is inadequate or not done.
It's inaccurate or not done.

1894
03:27:33,540 --> 03:27:40,920
SPEAKER: We are really bad at delivering enteral 
nutrition, especially in our ICUs. There are some  

1895
03:27:40,920 --> 03:27:47,460
studies that would suggest that patients get 40% 
or less of the prescribed calories during their  

1896
03:27:47,460 --> 03:27:57,359
ICU stays. This is due to interruptions due to 
procedures and perceived GI intolerance. There's  

1897
03:27:57,359 --> 03:28:03,839
a great fear of using parenteral nutrition for 
calorie adequacy, and there are studies that  

1898
03:28:03,840 --> 03:28:11,160
would suggest, at least in the very short term, 
that it has no benefit. And I'm partly to blame  

1899
03:28:11,160 --> 03:28:17,819
for that fear, because we always thought 
that parenteral nutrition was causal in in  

1900
03:28:17,819 --> 03:28:23,040
worse outcomes. There's new data that suggests 
that it's not the parenteral nutrition itself,  

1901
03:28:23,040 --> 03:28:29,100
but rather the patient's underlying condition 
that is more determinant in short term ICU  

1902
03:28:29,100 --> 03:28:35,399
studies. Randomized controlled ICU studies 
do not show a difference between parenteral  

1903
03:28:35,399 --> 03:28:41,580
and enteral nutrition outcomes in patients 
who are randomized to get one or the other.  

1904
03:28:41,580 --> 03:28:48,420
And then there are worries about the IRBs and 
research ethics, starving, "starved people." 

1905
03:28:48,420 --> 03:28:53,520
So malnourished patients or...I should 
say patients with malnutrition have always  

1906
03:28:53,520 --> 03:28:58,380
been excluded. And then there are issues of 
funding, because this is not an expensive drug.  

1907
03:28:59,160 --> 03:29:06,479
So ideally, we would have studies where we 
deliver 100% of the entire prescribed feed. And  

1908
03:29:06,479 --> 03:29:12,779
I've listed some of the possible things that have 
had impact that that have been shown. The first  

1909
03:29:12,779 --> 03:29:18,540
step randomized trial would be to feed versus not 
feed and/or feeding various amounts and analyze  

1910
03:29:18,540 --> 03:29:26,880
for the predictive characteristics and then apply 
those in a second randomized trial. I (INAUDIBLE)  

1911
03:29:26,880 --> 03:29:31,620
this thing and I look forward to discussing 
this at our discussion session coming up.

1912
03:29:31,620 --> 03:29:39,059
DR. PHILIPP SCHUETZ: Hello, everyone. My name 
is Philipp Schuetz, and I am a Professor of  

1913
03:29:39,060 --> 03:29:45,300
Internal Medicine and Nutritional Medicine 
at the Kantonsspital Aarau in Switzerland.  

1914
03:29:45,300 --> 03:29:50,520
And today, I'd like to talk to you about the 
question "Does a malnutrition diagnosis predict  

1915
03:29:50,520 --> 03:29:58,080
who will benefit from nutritional support?" Often, 
when we see patients at risk for malnutrition,  

1916
03:29:58,080 --> 03:30:05,279
we discuss whether this patient actually have...has 
malnutrition or not, but I think the much more  

1917
03:30:05,279 --> 03:30:11,519
interesting and important question is whether the 
patient will benefit from nutritional treatment.  

1918
03:30:13,500 --> 03:30:20,220
So why do we more talk about whether the patients 
have malnutrition and have less information about  

1919
03:30:20,220 --> 03:30:26,460
treatment response? And I think historically, 
when we look at the different malnutrition  

1920
03:30:26,460 --> 03:30:32,040
screening tools, we have to understand that 
most of these tools were actually developed  

1921
03:30:32,040 --> 03:30:40,080
based on their prognostic potential to identify a 
high-risk patient. So we looked at parameters that  

1922
03:30:40,080 --> 03:30:47,760
would predict mortality or complications, but we 
did not have a good database based on randomized  

1923
03:30:47,760 --> 03:30:54,359
trials to understand which of these different 
parameters actually separates patients who will  

1924
03:30:54,359 --> 03:31:02,519
benefit from support and not from support.
We have recently completed a very large  

1925
03:31:02,520 --> 03:31:08,279
nutritional trial, The EFFORT Trial. And 
EFFORT here stands for effect of nutritional  

1926
03:31:08,279 --> 03:31:15,899
treatment on frailty and functional outcomes in 
medical inpatients. And so this trial basically  

1927
03:31:15,899 --> 03:31:23,460
studied the question whether nutritional 
support in the inpatient setting helps  

1928
03:31:23,460 --> 03:31:30,540
medical inpatients and improves their clinical 
outcomes beyond that of nutritional outcomes.  

1929
03:31:31,560 --> 03:31:37,560
So this was a randomized trial. You see, we did 
a screening of patients. We had a few exclusion  

1930
03:31:37,560 --> 03:31:43,080
criteria, including critical care or surgical 
patients, patients with long-term nutrition,  

1931
03:31:43,080 --> 03:31:50,160
or terminal patients. And all included patients 
gave written informed consent. All of them had a  

1932
03:31:50,160 --> 03:31:55,260
nutritional risk screening score of three points 
or more, so they all had an increased risk. And  

1933
03:31:55,260 --> 03:32:01,260
they were randomized to an interventional group 
and a control group. So the control group received  

1934
03:32:01,260 --> 03:32:07,080
nutritional treatment based on the hospital 
usual care, so just by the hospital kitchen,  

1935
03:32:07,080 --> 03:32:13,439
but without defining individualized goals.
In the intervention group, however, we had a  

1936
03:32:13,439 --> 03:32:19,919
dietician team who met with all the patients and 
developed a nutritional plan to provide optimal  

1937
03:32:19,920 --> 03:32:27,660
nutritional care to the patients. And so here, you 
see this chart showing you how that intervention  

1938
03:32:27,660 --> 03:32:35,099
was done in the trial. So the first step was risk 
screening. So here, we used the NRS 2002. For all  

1939
03:32:35,100 --> 03:32:40,080
included patients, we then defined individual 
nutritional targets, including energy targets,  

1940
03:32:40,080 --> 03:32:46,920
protein targets, micronutrient targets, and 
other specific disease-specific targets.  

1941
03:32:47,520 --> 03:32:54,359
And after the definition of these different 
goals, we also came up with an individualized  

1942
03:32:54,359 --> 03:33:00,299
nutritional intervention plan to reach these 
goals, starting with oral nutrition, often,  

1943
03:33:00,300 --> 03:33:06,300
also with the use of oral nutritional supplements. 
But if a patient could not reach the goals,  

1944
03:33:07,140 --> 03:33:12,660
at least 75% of the goals within 5 days, 
we then also have an escalation protocol  

1945
03:33:12,660 --> 03:33:18,899
through enteral or parenteral nutrition, with the 
overall goal to reach the nutritional targets.  

1946
03:33:20,279 --> 03:33:26,460
So, these are the principal findings of this trial.
In the upper part, you see the risk of severe  

1947
03:33:26,460 --> 03:33:31,380
complications, and in the lower part you 
see mortality. And you see the blue group  

1948
03:33:31,380 --> 03:33:36,899
is the control group and the red group is 
the intervention group. And so it's clear  

1949
03:33:36,899 --> 03:33:44,399
from the trial that the risk to have a severe 
complication was significantly reduced by the  

1950
03:33:44,399 --> 03:33:50,639
provision of nutritional treatment. You see here 
a number needed to treat of 25 tells us that for  

1951
03:33:50,640 --> 03:33:58,500
every 25 patients we treat, we can we can reduce 
one severe complication. And also for mortality,  

1952
03:33:58,500 --> 03:34:06,600
we had a significant result with a number 
needed to treat of 37. So for about 40 patients  

1953
03:34:06,600 --> 03:34:12,540
that received nutrition treatment, you could 
prevent one death within 30 days. So nutrition,  

1954
03:34:12,540 --> 03:34:18,479
based on the trial results here, is a very 
effective treatment to improve clinical outcomes.  

1955
03:34:19,680 --> 03:34:26,939
And also, when you take this trial, look at this 
trial within a meta analysis of all trials looking  

1956
03:34:26,939 --> 03:34:33,479
at the medical inpatient population, you see 
there is now about 6,000 patients in such trials,  

1957
03:34:33,479 --> 03:34:38,399
and you see there is an overall effect 
regarding mortality reduction of about 25%. 

1958
03:34:38,939 --> 03:34:45,960
So patients at nutritional risk who receive 
nutritional treatment have about a 25% reduction  

1959
03:34:45,960 --> 03:34:54,779
in their risk of mortality. So the trials have 
looked at a very broad patient population. And  

1960
03:34:54,779 --> 03:34:59,519
of course, the question is well, do all these 
patients included [inaudible] benefit, or should be  

1961
03:34:59,520 --> 03:35:06,960
more personalized nutrition? Do we have patients 
that may not (INAUDIBLE)? And so traditionally,  

1962
03:35:06,960 --> 03:35:11,880
you would just treat an overall population and 
maybe you have some patients that have benefits.  

1963
03:35:11,880 --> 03:35:16,439
So these are the orange patients here in this 
cartoon. You have maybe some patients with  

1964
03:35:16,439 --> 03:35:21,000
no benefit and even some patients that have 
harm from the interventions, the blue ones.  

1965
03:35:22,140 --> 03:35:27,479
And what we want to do is go to a stratified 
medicine where we understand which groups are the  

1966
03:35:27,479 --> 03:35:34,859
ones that show most benefit. And, optimally, like 
in in oncology, we would go to precision medicine  

1967
03:35:34,859 --> 03:35:41,460
in nutritional care to really understand, based 
on the clinical presentation (maybe the blood  

1968
03:35:41,460 --> 03:35:47,939
biomarkers, maybe genetic information), which of 
the patients which patient needs nutrition and  

1969
03:35:47,939 --> 03:35:54,299
maybe also what type of nutrition the patient 
needs for his or her specific condition. 

1970
03:35:55,920 --> 03:36:02,700
So we did now. Based on the EFFORT Trial data, 
we did now a couple of sub analyses to better  

1971
03:36:02,700 --> 03:36:08,939
understand if we can find predictors for treatment 
response. And so one of the big question was  

1972
03:36:08,939 --> 03:36:15,660
whether the malnutrition screening assessment 
would be predictive of treatment response.  

1973
03:36:15,660 --> 03:36:20,760
And you see we calculated based on the 
patient's data. We calculated five well-known  

1974
03:36:21,779 --> 03:36:26,759
screening tools. And first, we looked at the 
prognostic value of these tools. And you see  

1975
03:36:26,760 --> 03:36:31,800
all of these screening tools show prognostic 
value. So the higher the risk in the screening,  

1976
03:36:31,800 --> 03:36:37,500
the higher the risk that a patient will die 
within 1 year. So this is 12 months follow up.  

1977
03:36:38,160 --> 03:36:43,859
However, we also did a second analysis and looked 
at treatment response. And so here, we did not  

1978
03:36:43,859 --> 03:36:49,620
find a very clear picture. So it's not that if 
a patient has a higher risk of malnutrition in  

1979
03:36:49,620 --> 03:36:54,779
these screening tools, that he would also show 
more benefit from nutritional intervention.  

1980
03:36:55,439 --> 03:37:00,599
The same was true when we looked at the GLIM 
criteria. And, you know, GLIM criteria seem to  

1981
03:37:00,600 --> 03:37:05,460
be much more specific compared to the screening 
tools towards the diagnosis of malnutrition. 

1982
03:37:05,460 --> 03:37:10,439
But again, GLIM criteria were also developed 
based on prognostic observational data,  

1983
03:37:10,439 --> 03:37:16,859
but not based on interventional data. So from 
GLIM, we do not know whether GLIM patients  

1984
03:37:16,859 --> 03:37:22,859
will have better treatment response. And so, 
when we looked at GLIM within our patients,  

1985
03:37:22,859 --> 03:37:28,739
again, we found that GLIM has a very strong 
prognostic value, and GLIM positive patients  

1986
03:37:28,739 --> 03:37:34,620
have a much higher risk of dying. Here, you even 
see 5-year outcome data, so long-term data.  

1987
03:37:35,460 --> 03:37:41,160
But again, when we looked at treatment response 
- and this is here at the upper part - you see  

1988
03:37:41,160 --> 03:37:46,739
that there was some trend that the GLIM positive 
patients may have a stronger response. So here  

1989
03:37:46,739 --> 03:37:54,239
the odds ratio was 0.6, and the GLIM negative ones 
had, still, an odds ratio of 0.85. So also, GLIM  

1990
03:37:54,239 --> 03:38:01,380
negative patients had a treatment response. So 
we looked also at other markers such as albumin,  

1991
03:38:01,380 --> 03:38:07,500
which is considered in some hospitals still to be 
a nutritional marker. And we found a very similar  

1992
03:38:07,500 --> 03:38:12,660
picture. Also, albumin is a prognostic 
marker, tells us about mortality risk,  

1993
03:38:12,660 --> 03:38:16,859
but does not help us to select a 
patient that will or will not respond. 

1994
03:38:17,640 --> 03:38:23,279
Now, the marker that actually showed the most 
promise regarding responsiveness to treatment  

1995
03:38:23,279 --> 03:38:29,219
was actually inflammation. And so within all 
our patients, we measured C-reactive protein,  

1996
03:38:29,220 --> 03:38:34,979
which is an inflammatory protein. And here, 
you see the stratified analysis, where overall,  

1997
03:38:34,979 --> 03:38:42,000
we had this nice benefit from the intervention 
regarding mortality within 30 days. And we  

1998
03:38:42,000 --> 03:38:47,100
found the same benefit in low-inflammation 
and moderate-inflammation patients. But in  

1999
03:38:47,100 --> 03:38:52,140
these patients with a C-reactive protein higher 
than 100 (so highly inflamed patients), you see  

2000
03:38:52,140 --> 03:38:58,319
that these two curves here turn and there was no 
more benefit regarding nutritional intervention  

2001
03:38:58,319 --> 03:39:04,259
for mortality reduction. And this was highly 
significant also in the interaction analysis.  

2002
03:39:05,460 --> 03:39:11,160
So, in summary, I think there is increasing 
evidence today that malnutrition is a strong  

2003
03:39:11,160 --> 03:39:16,800
risk factor but also a modifiable risk factor. 
And we have to be active in our patients in the  

2004
03:39:16,800 --> 03:39:21,960
hospital. We need to do proactive screening 
and start nutritional support protocols to  

2005
03:39:21,960 --> 03:39:28,260
reduce the high mortality and complication rate.
However, I think in the future, we need to better  

2006
03:39:28,260 --> 03:39:33,960
differentiate between diagnosis and treatment 
response. And the screening tools we use today,  

2007
03:39:33,960 --> 03:39:39,720
there are more diagnostic prognostic tools, 
and they are not necessarily telling us about  

2008
03:39:39,720 --> 03:39:45,060
treatment response. And so I think here in the 
future, we need to do more interventional studies,  

2009
03:39:45,060 --> 03:39:51,420
interventional trials, to really understand 
what are the parameters that tell us a patient  

2010
03:39:51,420 --> 03:39:57,779
will respond to nutritional intervention and, more 
specifically maybe, which patient needs which type  

2011
03:39:57,779 --> 03:40:03,779
of nutritional support. And with that, I'd like 
to close. And thank you again for your attention.

2012
03:40:03,779 --> 03:40:12,599
DR. PATRICK STOVER: It's a pleasure to be with you today 
to talk about causes, consequences,  

2013
03:40:12,600 --> 03:40:17,880
and treatment of micronutrient deficiencies over 
the next 10 minutes. And please note that I'm  

2014
03:40:17,880 --> 03:40:23,340
going to be talking about deficiencies associated 
with diseased populations (those you would find in  

2015
03:40:23,340 --> 03:40:28,859
the clinic) rather than healthy populations. And 
I would like to start with this workshop report  

2016
03:40:28,859 --> 03:40:35,339
from the National Academy of Sciences a few years 
ago talking about special nutritional needs. That  

2017
03:40:35,340 --> 03:40:42,000
is what...describing the evidence that we have to 
date on how the disease processes themselves can  

2018
03:40:42,000 --> 03:40:48,660
alter nutritional needs. And, of course, this is 
an important question because as of 2014, it was  

2019
03:40:48,660 --> 03:40:55,139
found about 60% of U.S. adults suffer from a chronic 
condition, 40% by more than one chronic condition.  

2020
03:40:56,220 --> 03:41:01,500
And so what this workshop does was really review 
the evidence for special nutritional requirements  

2021
03:41:01,500 --> 03:41:07,020
in disease states and medical conditions that 
can't be met with a normal diet. And so the  

2022
03:41:07,020 --> 03:41:12,239
workshop addressed that following list below of 
conditions where, in fact, we do have evidence  

2023
03:41:12,239 --> 03:41:19,800
that disease can alter nutritional requirements.
Now, this idea that disease processes affect  

2024
03:41:19,800 --> 03:41:24,120
nutritional requirements goes back to the 
early 1970s and work by Victor Herbert.  

2025
03:41:24,960 --> 03:41:30,779
But what he talked about was how disease related 
etiology, whether it's inflammation, genetic  

2026
03:41:30,779 --> 03:41:35,279
predisposition, autoimmunity, mitochondrial 
dysfunctions, pharmaceuticals, trauma,  

2027
03:41:35,279 --> 03:41:43,139
or the combination of these impact physiological 
functions that then impact nutrients and their  

2028
03:41:43,140 --> 03:41:50,640
function. They can affect gut absorption. They 
can affect the brain nerve barrier. You know that  

2029
03:41:50,640 --> 03:41:56,640
certain nutrients are concentrated several fold 
across the blood brain barrier, and loss of that  

2030
03:41:56,640 --> 03:42:02,160
concentration of nutrients in the brain can result 
in disease. It can cause increased degradation and  

2031
03:42:02,160 --> 03:42:08,220
turnover of nutrients, altered excretion patterns, 
altered metabolism, altered tissue distribution.  

2032
03:42:09,060 --> 03:42:14,700
And these physiological changes then can 
impact both human nutrition resulting in  

2033
03:42:14,700 --> 03:42:22,380
whole-body nutrient deficiencies or sometimes 
tissue-specific nutrient status. That is,  

2034
03:42:22,380 --> 03:42:27,720
the disease process that's isolated to a 
certain tissue can experience deficiency of  

2035
03:42:27,720 --> 03:42:33,300
nutrients in the absence of whole-body deficiency.
We can get new conditionally essential nutrients.  

2036
03:42:33,300 --> 03:42:41,220
We can get new nutrient toxicities. And, of 
course, during the regenerative phase of recovery  

2037
03:42:41,220 --> 03:42:46,200
from chronic disease, we have to worry about stem 
cell and stem cell nutrition, which have different  

2038
03:42:46,200 --> 03:42:52,620
nutritional requirements from differentiated 
cells. We also know that disease, independent  

2039
03:42:52,620 --> 03:42:58,620
of its effect on human nutrition, can also impact 
biomarkers that we use to assess nutrient status  

2040
03:42:58,620 --> 03:43:03,840
and function. And so, we have to be mindful that 
when we see a change in these biomarkers in  

2041
03:43:03,840 --> 03:43:11,100
disease, it may not necessarily mean that actual 
nutrient status or nutrient requirements differ.  

2042
03:43:13,080 --> 03:43:19,200
So, in this slide, this just illustrates the 
challenges of establishing special nutritional  

2043
03:43:19,200 --> 03:43:24,479
requirements. To the left in blue, you see 
healthy populations, where we derive dietary  

2044
03:43:24,479 --> 03:43:30,120
reference intakes to meet their nutritional 
needs using various types of biomarkers that are  

2045
03:43:30,120 --> 03:43:36,359
listed there. Looking at a whole body, nutrient 
status, function, clinical outcomes. You see to  

2046
03:43:36,359 --> 03:43:42,120
the right in red though, we have about half of 
the adult population that has a chronic disease. 

2047
03:43:42,120 --> 03:43:48,000
And not only do we have to understand nutrient 
status in the relevant biomarkers that we do  

2048
03:43:48,000 --> 03:43:54,060
for healthy populations, but we have 
to consider other considerations, like  

2049
03:43:54,060 --> 03:44:00,480
tissue-specific nutrient status, like restoration 
of function through tissue regeneration that may  

2050
03:44:01,620 --> 03:44:08,580
prescribe, if you will, different nutrient 
requirements. So, a few factors that we know  

2051
03:44:08,580 --> 03:44:15,479
actually affect nutrient status and/or biomarkers 
of status and disease. One, in some diseases we  

2052
03:44:15,479 --> 03:44:21,839
see increased rates of nutrient catabolism. One 
of the most studied examples of this is acquired  

2053
03:44:21,840 --> 03:44:27,660
Arginase Deficiency Syndrome, where in certain 
disease states, or as a result of trauma in cancer  

2054
03:44:28,500 --> 03:44:33,660
or surgery, you actually see an increase in 
the expression of the enzyme arginase that  

2055
03:44:33,660 --> 03:44:40,800
then begins to degrade all of the arginine. When 
this happens then, the patient becomes deficient,  

2056
03:44:40,800 --> 03:44:46,979
if you will, in that amino acid, and, in fact, 
their recovery is much improved if they are given  

2057
03:44:46,979 --> 03:44:53,339
supplemental arginine. We also see the disease 
can affect tissue redistribution and/or excretion. 

2058
03:44:53,880 --> 03:45:02,279
We know that infection affects iron levels in the 
plasma and biomarkers of iron levels. Now, does  

2059
03:45:02,279 --> 03:45:08,519
this redistribution mean a change in requirement? 
That's still an open question. We also know that  

2060
03:45:08,520 --> 03:45:13,260
inflammation can affect tissue distribution of 
vitamin B6, where it disappears from plasma,  

2061
03:45:13,260 --> 03:45:20,040
vitamin D, and others. So, you see here where you 
can get a redistribution effect due to a disease  

2062
03:45:20,040 --> 03:45:25,140
or an infection, whether or not that actually is 
a nutritional deficiency remains an open question.  

2063
03:45:26,040 --> 03:45:32,220
We see decreased uptake across barriers, including 
the gut barrier, but also the blood/brain barrier,  

2064
03:45:32,220 --> 03:45:37,800
which again concentrates certain nutrients in 
the brain. And this can be caused by genetics,  

2065
03:45:37,800 --> 03:45:44,640
inflammation, drug use, autoimmunity, and others. 
But we see in bariatric surgery that following  

2066
03:45:44,640 --> 03:45:50,640
bariatric surgery, deficiencies in 
vitamins, including B12, B1, AKC,  

2067
03:45:50,640 --> 03:45:59,279
and folate, are not uncommon, and, in fact, some 
supplemental quantities of these micronutrients  

2068
03:45:59,279 --> 03:46:04,259
are required to maintain nutritional status. We 
see the same with the minerals that are listed. 

2069
03:46:04,800 --> 03:46:09,420
Similarly, in IBD and other 
inflammatory conditions in the gut,  

2070
03:46:09,420 --> 03:46:16,080
we also see nutrient deficiencies 
that result from that disease process.  

2071
03:46:17,220 --> 03:46:23,160
We also see when enduring regenerative phases 
following chronic disease or following injury,  

2072
03:46:23,160 --> 03:46:28,260
we have to expand our stem cell populations 
and we're having increased evidence that in  

2073
03:46:28,260 --> 03:46:33,239
fact stem cells have different nutritional 
requirements from fully differentiated cells.  

2074
03:46:33,239 --> 03:46:39,300
The Thalacker-Mercer Lab recently published a paper 
that showed that myoblasts have a requirement  

2075
03:46:39,300 --> 03:46:46,500
for serine and glycine. They do not synthesize 
sufficient amounts for myoblast proliferation and  

2076
03:46:46,500 --> 03:46:52,200
differentiation, and so therefore, they have 
a special requirement for those amino acids.  

2077
03:46:53,460 --> 03:46:59,819
We also know that drugs can alter nutrition needs. 
There was a study a couple of years ago that  

2078
03:46:59,819 --> 03:47:06,359
showed that the ACE inhibitor drug Enalapril 
is more efficacious when it's used in combination  

2079
03:47:06,359 --> 03:47:13,019
with supplemental folic acid. It's also known 
that when this drug is administered in the  

2080
03:47:13,020 --> 03:47:19,979
absence of folic acid, it actually affects plasma 
folate levels and biomarkers of folate function. 

2081
03:47:19,979 --> 03:47:25,739
It's not known how this occurs, but you 
can see the the drugs can alter nutrient  

2082
03:47:25,739 --> 03:47:31,019
requirements. Sometimes their efficacy 
can affect can be affected by nutrients.

2083
03:47:31,020 --> 03:47:36,540
SPEAKER: However, this is not considered 
a special nutritional requirement where  

2084
03:47:36,540 --> 03:47:40,859
the FDA mandates that when a drug 
does have an effect on nutrition,  

2085
03:47:40,859 --> 03:47:45,120
that that extra nutrition support, if 
you will, be administered with the drug.  

2086
03:47:46,500 --> 03:47:51,420
So, we can learn a lot about special nutritional 
requirements from the long history of work done on  

2087
03:47:51,420 --> 03:47:58,319
inborn errors of metabolism, where medical foods 
have been formulated with different concentrations  

2088
03:47:58,319 --> 03:48:04,920
of nutrients or addition or subtraction of 
certain metabolites to overcome the genetic  

2089
03:48:04,920 --> 03:48:09,779
deficit associated with that inborn error 
of metabolism. And the open question is,  

2090
03:48:09,779 --> 03:48:15,059
in chronic disease, can we take the same approach, 
where chronic disease results in a loss of  

2091
03:48:15,060 --> 03:48:20,880
function? And can we understand that a systems 
level how those nutritional needs are different?  

2092
03:48:22,020 --> 03:48:25,140
This is an example we see from 
the inborn error of metabolism,  

2093
03:48:25,140 --> 03:48:32,220
where you have cerebral folate deficiency due 
to either mutations in the folate receptor,  

2094
03:48:32,220 --> 03:48:37,800
you can see there, or due to mitochondrial 
dysfunction, or due to autoantibodies, you end  

2095
03:48:37,800 --> 03:48:43,859
up getting a deficiency of folate in the brain.
This can be overcome with very high-dose folate  

2096
03:48:43,859 --> 03:48:50,639
and a particular form, that is folinic acid. Folic 
acid itself will not restore brain levels. So  

2097
03:48:50,640 --> 03:48:55,800
again, we have good examples of how to approach 
these sort of special nutritional requirements.  

2098
03:48:56,700 --> 03:49:02,519
Do we have frameworks to establish them? 
Absolutely. I think many of you are probably aware  

2099
03:49:02,520 --> 03:49:07,859
of this framework that was published some years 
ago by Russell. But we can look at exposures,  

2100
03:49:07,859 --> 03:49:13,139
nutrient exposures, and we can directly connect 
them to a clinical outcome in either a healthy  

2101
03:49:13,140 --> 03:49:20,580
or a disease population. We also need to establish 
validated surrogate outcomes that aren't affected  

2102
03:49:20,580 --> 03:49:26,399
by the disease, but that respond to the nutrient 
exposure and then report on what that clinical  

2103
03:49:26,399 --> 03:49:32,160
outcome is going to be. We also can, again, 
continue to look at indicator of status  

2104
03:49:32,160 --> 03:49:36,899
biomarkers that then connect to the clinical 
outcome that again are independent of the disease  

2105
03:49:36,899 --> 03:49:44,639
process as well as nonvalidated markers. So, in 
conclusion, we do have gaps in future directions.  

2106
03:49:45,720 --> 03:49:52,859
One real need is to develop system biomarkers that 
really link disease to nutritional needs, both in  

2107
03:49:52,859 --> 03:49:58,380
healthy populations and unhealthy populations.
If we understand what systems are affected,  

2108
03:49:58,380 --> 03:50:05,939
what nutrients are affected with those systems, we 
can systematically then be able to prescribe how  

2109
03:50:05,939 --> 03:50:12,660
to rejuvenate those systems in the disease state 
and do it in a way that is low cost. We have to  

2110
03:50:12,660 --> 03:50:18,899
remember that status and functional biomarkers in 
disease don't necessarily indicate true whole-body  

2111
03:50:18,899 --> 03:50:24,239
deficiencies. Sometimes the disease itself 
is just modifying the marker without really  

2112
03:50:24,239 --> 03:50:31,559
affecting nutrient status, and sometimes we have 
to consider tissue-specific deficiency and whether  

2113
03:50:31,560 --> 03:50:36,360
or not we have markers to report on those as 
opposed to a whole-body or systemic deficiency.  

2114
03:50:37,620 --> 03:50:43,859
We have to remember that disease comorbidities 
may be due to disease-induced nutritional  

2115
03:50:43,859 --> 03:50:49,679
Deficiencies. That is, for example, you have the 
disease of diabetes that can lead to peripheral  

2116
03:50:49,680 --> 03:50:54,840
neuropathies. Well, there's some evidence, in 
fact, that peripheral neuropathy results from  

2117
03:50:54,840 --> 03:51:01,620
a alteration in nutrient needs caused by diabetes 
itself. There's strong animal literature for that.  

2118
03:51:02,340 --> 03:51:07,260
We have to understand that the cause of 
deficiency and that's going to be important  

2119
03:51:07,260 --> 03:51:10,920
because it may indicate what form 
of nutrient is needed in disease. 

2120
03:51:10,920 --> 03:51:15,180
We see this in the case of folate. We also see 
it in the case of vitamin A and other nutrients  

2121
03:51:15,180 --> 03:51:20,040
where the disease may dictate a specific form 
of the nutrient that works as opposed to others.  

2122
03:51:20,819 --> 03:51:25,259
And we also have to remember that sometimes you 
can have a true nutritional deficiency caused by  

2123
03:51:25,260 --> 03:51:31,260
disease and supplementation may not resolve that 
deficiency, such as what you see in pernicious  

2124
03:51:31,260 --> 03:51:36,779
anemia and vitamin B12. So with that, I thank 
you very much for your time and attention.

2125
03:51:36,779 --> 03:51:45,960
DR. KATHERINE TUCKER: Good afternoon. I've been asked to talk about 
the nutritionally vulnerable and hidden hunger.  

2126
03:51:47,340 --> 03:51:52,140
As we've been hearing today, malnutrition 
is common in hospitalized patients,  

2127
03:51:52,140 --> 03:52:00,600
and screening is often inadequate. There 
are different definitions of malnutrition.  

2128
03:52:01,319 --> 03:52:08,399
The European Society for Parental and Enteral 
Nutrition considers fat-free mass as a central  

2129
03:52:08,399 --> 03:52:17,279
component. The American Society considers any two 
of the following: weight loss, low energy intake,  

2130
03:52:17,939 --> 03:52:25,500
handgrip strength, loss of muscle mass, loss 
of subcutaneous fat, or fluid accumulation.  

2131
03:52:28,800 --> 03:52:34,800
I checked in our local hospital and found 
that the screening tool that they're using  

2132
03:52:35,399 --> 03:52:41,639
selects the two easiest of these: have 
you recently lost weight without trying,  

2133
03:52:42,600 --> 03:52:46,440
and have you been eating poorly 
because of decreased appetite?  

2134
03:52:48,779 --> 03:52:55,080
Although this is good to be screening 
for malnutrition in this way,  

2135
03:52:55,800 --> 03:53:05,399
what it's unlikely to catch in many cases is 
sarcopenic obesity. And we know now that with the  

2136
03:53:05,399 --> 03:53:13,679
growing prevalence of obesity in our population, 
that sarcopenic obesity is also increasing. 

2137
03:53:14,340 --> 03:53:18,359
These data from the NHANES III, 
which is now quite old, where the  

2138
03:53:18,359 --> 03:53:26,219
prevalence of sarcopenic obesity-defined as 
a combination of obesity and low muscle mass-  

2139
03:53:26,880 --> 03:53:30,960
the prevalence in men was about 10% and women 7%.  

2140
03:53:37,080 --> 03:53:42,779
However, this has been increasing rapidly 
since that time, and recent estimates show  

2141
03:53:44,040 --> 03:53:52,140
that it may affect more than 23% of those over 75 
years of age. And we know that sarcopenic obesity  

2142
03:53:52,140 --> 03:53:59,399
poses patients at risk of frailty, disability, 
morbidity, and mortality. One study showed that  

2143
03:53:59,399 --> 03:54:06,599
survival time was significantly lower among 
adults aged 50 to 70 with sarcopenic obesity.  

2144
03:54:08,220 --> 03:54:11,880
The trick is that this requires 
measurement of muscle mass,  

2145
03:54:11,880 --> 03:54:15,900
either by DEXA or bioelectrical 
impedance, and this is rarely done.  

2146
03:54:21,000 --> 03:54:27,420
Beyond muscle wasting itself, malnutrition 
in hospitalized patients takes the form of  

2147
03:54:27,420 --> 03:54:31,020
micronutrient deficiencies. And you've 
just heard a little bit about that.  

2148
03:54:31,979 --> 03:54:39,179
In this case, this is the NHANES dietary 
intake data showing that most older adults  

2149
03:54:39,180 --> 03:54:46,020
have low intakes of critical nutrients, 
including dietary fiber, vitamins, and minerals. 

2150
03:54:49,260 --> 03:54:56,880
Why is this important to consider in hospitalized 
patients? Well, in addition to protein, which is  

2151
03:54:56,880 --> 03:55:04,560
associated with loss of muscle mass and decreased 
immunity, N-3 fatty acids and dietary fiber are  

2152
03:55:04,560 --> 03:55:14,280
both related to inflammation, and vitamins and 
minerals are associated with wound healing,  

2153
03:55:14,939 --> 03:55:23,699
resistance to infection, diabetes 
control, anemia, and other conditions.  

2154
03:55:27,960 --> 03:55:34,560
The Mini Nutritional Assessment tool is a tool 
that's been very commonly used throughout the  

2155
03:55:34,560 --> 03:55:40,140
world, and I like it because it includes 
in its full form questions about diet,  

2156
03:55:40,140 --> 03:55:45,420
questions about protein foods, and 
about fruits and vegetables. Although  

2157
03:55:45,420 --> 03:55:49,979
the long form is not that long, it 
still takes a little bit of time,  

2158
03:55:49,979 --> 03:55:56,399
so they have created a shorter form, which 
unfortunately does drop the dietary questions.  

2159
03:56:01,080 --> 03:56:08,399
Dietary screening remains important, however, 
particularly for these micronutrients. And  

2160
03:56:08,399 --> 03:56:13,559
so I was involved in the early stages of 
development of the Geisenger Rural Aging  

2161
03:56:13,560 --> 03:56:20,760
Study Rapid Dietary Screening Tool. This tool 
has 25 food and behavior related questions,  

2162
03:56:21,600 --> 03:56:28,140
and it's been validated, one, by looking at 
dietary patterns created from those answers,  

2163
03:56:28,140 --> 03:56:36,359
which showed significant associations between 
a healthy diet with higher HDL cholesterol and  

2164
03:56:36,359 --> 03:56:42,000
physical activity and lower serum triglycerides 
and waist circumference, and with a Western  

2165
03:56:42,000 --> 03:56:47,939
or poor diet, which was significantly 
associated with lower serum vitamin B12. 

2166
03:56:50,399 --> 03:56:56,639
It's also been validated against a healthy eating 
index, which was derived from three 24-hour  

2167
03:56:56,640 --> 03:57:05,160
recalls, and that showed that the DST score 
correlated significantly with HEI and that those  

2168
03:57:05,160 --> 03:57:11,639
at risk from the DST score had significantly 
lower HEI scores than those not at risk.  

2169
03:57:13,500 --> 03:57:18,540
The DST score was also significantly 
associated with serum carotenoids  

2170
03:57:19,739 --> 03:57:22,139
and importantly with 8-year mortality,  

2171
03:57:24,479 --> 03:57:34,979
24% reduction in risk among those with the high 
score versus lower. These are the questions on the  

2172
03:57:34,979 --> 03:57:40,799
score. I apologize, this isn't terribly clear,
but basically there are questions like how often  

2173
03:57:40,800 --> 03:57:48,420
do you usually eat fruit as a snack? Do you drink 
some kind of juice? How often do you eat carrots,  

2174
03:57:48,420 --> 03:57:52,680
sweet potatoes, broccoli, or spinach? 
And each of these has a point value.  

2175
03:57:54,960 --> 03:57:59,040
A patient is considered at risk 
if the score is less than 60.  

2176
03:58:01,859 --> 03:58:09,120
So, in addition to dietary intake scores, how do 
we identify those that are most nutritionally  

2177
03:58:09,120 --> 03:58:16,019
vulnerable with hidden hunger? Well, one of 
the key indicators of this is food insecurity. 

2178
03:58:16,620 --> 03:58:24,000
Food insecurity is estimated to affect more 
than 15 million households in 2017. It's part  

2179
03:58:24,000 --> 03:58:29,580
of the social determinants of health, which 
are gaining steam as something to investigate  

2180
03:58:29,580 --> 03:58:37,680
in order to evaluate risk. Of course, these social 
determinants tend to be most problematic in those  

2181
03:58:37,680 --> 03:58:45,779
with low income, certain minority groups, or single 
parent households. And food insecurity has been  

2182
03:58:45,779 --> 03:58:52,979
associated clearly with higher risk of diabetes 
and diabetes control, hypertension, dyslipidemia,  

2183
03:58:52,979 --> 03:59:02,399
depression, and cardiovascular disease. Screening 
is recommended. It's ideal to use a standard  

2184
03:59:02,399 --> 03:59:08,939
18-item questionnaire, which has been well 
validated and tested, but two questions have  

2185
03:59:08,939 --> 03:59:15,540
been identified which show good sensitivity and 
specificity. These include simply asking, within  

2186
03:59:15,540 --> 03:59:21,180
the past 12 months, were you worried that food 
would run out before you got money to buy more?  

2187
03:59:23,819 --> 03:59:32,099
And was the food you bought lasting, and and did 
you have enough money to get more if needed?  

2188
03:59:33,479 --> 03:59:38,819
Patients identified as food insecure should be 
connected with food assistance programs, as when  

2189
03:59:38,819 --> 03:59:44,160
they returned home after hospitalization.
This can make a large difference.  

2190
03:59:46,739 --> 03:59:52,500
As an example, we looked at food 
insecurity in our study in Boston,  

2191
03:59:52,500 --> 03:59:59,699
Puerto Rican adults age 45 to 75. We 
found that 17.4% were food insecure.  

2192
04:00:00,840 --> 04:00:08,100
Factors associated with food insecurity included 
medium acculturation versus higher or lower- 

2193
04:00:08,100 --> 04:00:12,060
interestingly, those that were trying 
to live in both Spanish and English,  

2194
04:00:13,020 --> 04:00:18,240
living far from a supermarket, and 
low availability of nutritious foods.  

2195
04:00:19,739 --> 04:00:23,699
Food insecurity was significantly 
associated with dietary quality,  

2196
04:00:23,699 --> 04:00:30,179
particularly with lower vegetable intake, with 
poor glycemic control among those with diabetes  

2197
04:00:30,840 --> 04:00:36,120
and with cognitive decline over two 
years, particularly in executive function.  

2198
04:00:38,699 --> 04:00:45,000
So in conclusion, nutrition screening 
is critical for patient care but is  

2199
04:00:45,000 --> 04:00:47,279
not always conducted. Further, it's important 
to move beyond wasting as the main criteria  

2200
04:00:47,279 --> 04:00:59,399
as many vulnerable patients are obese but still 
sarcopenic. Micronutrients cannot be ignored as  

2201
04:00:59,399 --> 04:01:05,399
intakes are insufficient in large segments of the 
population and brief dietary screeners can help. 

2202
04:01:06,300 --> 04:01:12,360
Finally, food security is a key indicator 
of risk and a point for action. Thank you.

2203
04:01:16,319 --> 04:01:19,620
DR. DAVID SERES: Thank you all for 
a really robust session and  

2204
04:01:21,359 --> 04:01:30,540
some very interesting topics. Dr. Tucker, 
on your food insecurity measures, have you  

2205
04:01:31,080 --> 04:01:38,399
gotten to the point where you do any studies on 
interventions to see if these affect outcomes?  

2206
04:01:39,899 --> 04:01:48,120
DR. KATHERINE TUCKER: Yes, actually, we're in the process of planning 
a study right now to provide meal kits to people  

2207
04:01:48,120 --> 04:01:52,199
in the communities with food insecurity 
and to see how that affects their health.  

2208
04:01:52,979 --> 04:01:56,580
DR. DAVID SERES: Excellent. Can everybody 
please turn on their cameras,  

2209
04:01:57,720 --> 04:02:06,960
it's separate from the microphone. Thank you. 
Alright, a couple of other questions for Dr.  

2210
04:02:06,960 --> 04:02:13,340
Stover. Are there micronutrients of concern with 
respect to deficiency in the healthy population?

2211
04:02:13,340 --> 04:02:24,420
DR. PATRICK STOVER: Thank you very much. The answer to 
that is they're certainly not common, at least in  

2212
04:02:24,420 --> 04:02:32,819
most industrialized Western nations. Although that 
just said, there was a very interesting study that  

2213
04:02:32,819 --> 04:02:37,319
should be published very soon in the American 
Journal of Clinical Nutrition that showed,  

2214
04:02:37,319 --> 04:02:43,920
in fact, in Ireland, where they used a gold 
standard method of detecting riboflavin status,  

2215
04:02:43,920 --> 04:02:52,500
one that's normally not used, found significant 
deficiency of riboflavin in the population. And  

2216
04:02:52,500 --> 04:02:59,699
this actually had cascading effects on other 
micronutrients because of the role of riboflavin  

2217
04:02:59,699 --> 04:03:05,519
cofactors in processing these other vitamins 
to become cofactors. So while they are not  

2218
04:03:05,520 --> 04:03:11,340
common and most of these are avoided through 
various fortification policies that we have,  

2219
04:03:12,600 --> 04:03:15,000
there are some that are unrecognized.

2220
04:03:16,939 --> 04:03:25,859
DR. DAVID SERES: So while we're sort of on that, there 
are a couple of questions both for you and for  

2221
04:03:25,859 --> 04:03:36,059
Katherine Tucker about including micronutrients 
in these assessments. Any thoughts on that?

2222
04:03:36,060 --> 04:03:42,720
DR. KATHERINE TUCKER: Well, as I as I said, I 
think it's really important. I think that there  

2223
04:03:43,920 --> 04:03:49,380
are a lot of people that may not have the 
frank deficiency diseases, but I think  

2224
04:03:49,380 --> 04:03:56,340
large segments of our population have subclinical 
micronutrient deficiencies. And if they come into  

2225
04:03:56,340 --> 04:04:04,920
the hospital with that predisposition, that they 
are going to do even worse in terms of outcomes.  

2226
04:04:04,920 --> 04:04:09,120
I think there needs to be a lot more 
focus on micronutrients, personally.

2227
04:04:12,840 --> 04:04:17,580
DR. DAVID SERES: OK, Dr. Schuetz, can you tell 
us what's different about your nutrition  

2228
04:04:17,580 --> 04:04:25,199
risk score such that you actually were able 
to predict response? What's different about  

2229
04:04:25,199 --> 04:04:31,380
that compared to all of these others that 
you've shown do not predict response?

2230
04:04:31,380 --> 04:04:37,859
DR. PHILLIP SCHUETZ: Yeah, well, I think as 
discussed in one of the earlier talks,  

2231
04:04:37,859 --> 04:04:44,519
most of the nutritional assessment and risk 
scores use kind of the same variables. So  

2232
04:04:44,520 --> 04:04:55,020
they look at the weight and appetite, BMI and 
I think all these variables, they are pretty good  

2233
04:04:55,020 --> 04:05:00,960
outcome predictors. Now in our analysis, 
we actually found that the strongest  

2234
04:05:01,620 --> 04:05:14,040
predictor for nutritional support were in fact 
inflammation. So, that was pretty interesting  

2235
04:05:14,040 --> 04:05:22,439
because we didn't know that inflammation is an 
important key driver for malnutrition. And if  

2236
04:05:22,439 --> 04:05:27,179
you have a patient with chronic inflammation, the 
risk of this patient to become malnourished and  

2237
04:05:28,500 --> 04:05:36,180
develop cachexia is much increased. But I think 
what was interesting in our data was to see that  

2238
04:05:36,180 --> 04:05:43,260
actually inflammation was negatively associated 
with the response to treatment. So this goes back  

2239
04:05:43,260 --> 04:05:53,460
to the old discussions we had, that patients with 
cachexia seem to have less pronounced response to  

2240
04:05:53,460 --> 04:05:59,399
nutritional interventions compared to patients 
with earlier or different types of malnutrition. 

2241
04:06:00,600 --> 04:06:06,720
And so I think that's very important 
that today we talk about malnutrition in  

2242
04:06:06,720 --> 04:06:13,220
patients that actually present with very 
different phenotypes of this condition.

2243
04:06:13,220 --> 04:06:21,359
DR. DAVID SERES: Yeah, you and I have talked about this. 
I was actually surprised that these other scores,  

2244
04:06:21,359 --> 04:06:27,719
which depends so heavily on inflammation, the 
phenomena of inflammation like edema and so  

2245
04:06:27,720 --> 04:06:33,720
forth, that they were not negatively predictive, 
they were just not predictive; I would have  

2246
04:06:33,720 --> 04:06:38,819
expected them to be negatively predictive. So 
this is an area that I think is really ripe for  

2247
04:06:38,819 --> 04:06:47,699
research. Char, and I apologize for going 
back and forth with first and last names,  

2248
04:06:47,699 --> 04:07:03,120
but I since I know you all, you mentioned that, 
sorry, the GLIM and A&D were validated to predict  

2249
04:07:06,359 --> 04:07:11,519
SGA scores and so forth, but just to 
verify that they have not been validated  

2250
04:07:11,520 --> 04:07:15,261
to predict response to nourishment, that's 
correct, right?

2251
04:07:15,261 --> 04:07:18,973
DR. CHARLENE COMPHER: Yeah, it is correct. Sadly, 

2252
04:07:19,500 --> 04:07:25,560
they have not been yet, but that needs 
to happen and needs to happen soon.  

2253
04:07:27,779 --> 04:07:33,359
I'd like to just follow up on something 
Dr. Schuetz just said that's in this line.  

2254
04:07:34,739 --> 04:07:45,000
I really liked your description of a strategic 
identification of groups among a large group of  

2255
04:07:45,000 --> 04:07:49,859
patients who will some will benefit, some 
may have no benefits, some may have harm. 

2256
04:07:49,859 --> 04:07:58,799
In your observations about the degree of 
inflammation, those with the highest inflammation,  

2257
04:07:58,800 --> 04:08:05,880
did they have harm or they just did not have 
the same benefit? DR. PHILIPP SCHUETZ: Yeah, that's an excellent  

2258
04:08:05,880 --> 04:08:15,540
question. So in our data, we had rather absence 
of benefit. However, when you look closer at  

2259
04:08:15,540 --> 04:08:23,100
the intensive care data and there are some 
large trials showing that you do overfeeding  

2260
04:08:24,600 --> 04:08:32,279
of patients is actually associated with adverse 
outcomes. So, the EPaNIC trial is this large  

2261
04:08:32,279 --> 04:08:41,819
trial from Belgium where they actually found that 
mortality and lengths of ICU stays increased if  

2262
04:08:41,819 --> 04:08:49,019
you use parenteral nutrition with very high doses 
of calories and protein in patients that are very  

2263
04:08:49,020 --> 04:08:56,640
severely metabolically stressed. So I think in the 
end the patients that are metabolically stressed,  

2264
04:08:56,640 --> 04:09:03,779
highly inflamed, and you give those patients too 
much nutrition, I think you can actually do harm  

2265
04:09:03,779 --> 04:09:10,439
in these patients. And we know today that we have 
re-feeding, but also overfeeding and possibly  

2266
04:09:11,760 --> 04:09:17,280
interaction with autophagy, are all mechanisms 
that have been discussed that could explain  

2267
04:09:17,939 --> 04:09:23,759
why these patients hurt if you use too much 
nutrition in a metabolically stressed patient. 

2268
04:09:25,859 --> 04:09:32,099
DR. DAVID SERES: Great. Patrick, do you have 
any suggestions for clinicians  

2269
04:09:33,120 --> 04:09:38,279
as a practical matter? How do you know 
whether or not you can trust the level  

2270
04:09:39,239 --> 04:09:44,219
of something if indeed all of these levels 
are affected by inflammation and so forth?

2271
04:09:44,220 --> 04:09:50,399
DR. PATRICK STOVER: Certainly. Well, I mean, this is 
an area where we certainly need a lot more  

2272
04:09:50,399 --> 04:09:54,660
research. There's been good work that has 
been done trying to correct iron status  

2273
04:09:54,660 --> 04:09:59,819
for markers of inflammation. There have 
been tempts to do this with vitamin B6,  

2274
04:10:01,260 --> 04:10:07,140
but by and large, we need to understand the 
functioning across the board of biomarkers,  

2275
04:10:07,140 --> 04:10:14,161
of micronutrient status and function, and whether 
or not they still hold true in states of disease.  

2276
04:10:14,699 --> 04:10:18,120
And so there's just a tremendous amount 
of work that needs to be done. Again,  

2277
04:10:18,120 --> 04:10:24,120
iron is one where there have been great inroads 
that have been made. But we need to understand is  

2278
04:10:24,120 --> 04:10:29,340
this a precision approach we have to take or can 
we actually classify certain diseases specific way  

2279
04:10:29,340 --> 04:10:36,900
and then have separate subgroup requirements for 
that group when they are in that disease state.  

2280
04:10:38,279 --> 04:10:43,739
And as has been mentioned, there's also the 
issue where, in disease, some people can do harm  

2281
04:10:43,739 --> 04:10:48,960
with increasing levels of a micronutrient 
that are meant to control for a deficiency,  

2282
04:10:48,960 --> 04:10:53,160
so a disease-induced deficiency.
So, there is just a lot of work that has to  

2283
04:10:53,160 --> 04:10:59,340
be done in this area. I thought that the workshop 
that the National Academy did in 2018 before the  

2284
04:10:59,340 --> 04:11:03,779
pandemic was a good start, but it's certainly 
an area where we just need a lot more research.

2285
04:11:05,880 --> 04:11:16,739
DR. DAVID SERES: Dr. Tucker, are you close to 
having a sense of the impact on hospital  

2286
04:11:19,140 --> 04:11:26,580
outcomes, on what is food insecurity doing 
to that? Do we have any of that kind of  

2287
04:11:26,580 --> 04:11:33,420
data directly looking at do people with 
food insecurity do poorly in the hospital?  

2288
04:11:34,199 --> 04:11:39,000
And then subsequently we talked about that 
and that's wonderful that you're intervening.  

2289
04:11:39,000 --> 04:11:43,199
But do you have anything that sort of says that it's 
predictive of poor outcomes in the hospital?

2290
04:11:43,199 --> 04:11:50,880
DR. KATHERINE TUCKER: Right now there is 
a ramp-up in interest in food  

2291
04:11:50,880 --> 04:11:55,620
insecurity, and there's a lot of research 
going on right now. It's been well funded  

2292
04:11:57,120 --> 04:12:02,040
and it's very important. Most of it 
has been in the community, honestly. 

2293
04:12:02,040 --> 04:12:07,279
There has not been a lot of food 
insecurity screening at the hospital level.

2294
04:12:07,279 --> 04:12:12,059
DR. DAVID SERES: Yeah, I'd love to 
see it translated across...

2295
04:12:12,060 --> 04:12:21,420
DR. KATHERINE TUCKER: I do know of... I am working with 
someone who is using AI with hospital records and  

2296
04:12:21,420 --> 04:12:27,300
they're trying to pick up food insecurity along 
with other social determinants of health, working  

2297
04:12:27,300 --> 04:12:33,930
with the large veterans data to see if they can 
predict some of these outcomes as well. I think...

2298
04:12:33,930 --> 04:12:36,060
DR. DAVID SERES: So somebody is... I'm sorry.

2299
04:12:36,060 --> 04:12:42,121
DR. KATHERINE TUCKER: No, I just think there still needs to 
be a lot of research to clarify these things.

2300
04:12:44,220 --> 04:12:52,620
DR. DAVID SERES: Someone asks, and I think this is 
for Dr. Schuetz. Are there those with a CRP  

2301
04:12:52,620 --> 04:13:00,120
greater than... Are those with a CRP greater than 
100 actually refractory to nutrition support?  

2302
04:13:01,080 --> 04:13:07,620
In other words, they're asking 
is this a sign for futility?

2303
04:13:07,620 --> 04:13:16,739
DR. PHILLIP SCHUETZ: Yeah, well, it's kind of hard to 
understand the data, really. And sometimes people  

2304
04:13:16,739 --> 04:13:22,139
ask me, well, what do you do with a patient with 
a very high CRP level that is highly inflamed? Are  

2305
04:13:22,140 --> 04:13:27,780
you just not going to feed this patient, although he's 
malnourished, right? And I think that's a tough question.  

2306
04:13:29,160 --> 04:13:36,180
So, I think in the end, we don't know how 
to best respond to the signal. But it's  

2307
04:13:36,180 --> 04:13:41,580
a very strong signal in the data that 
patients that are highly inflamed just  

2308
04:13:41,580 --> 04:13:47,460
seem to respond differently. And so maybe we 
need to use a different type of nutrition.  

2309
04:13:48,600 --> 04:13:55,080
And we know there is some types of nutrition that 
seem to modulate the inflammatory response. So  

2310
04:13:55,080 --> 04:14:07,380
immunonutrition or also some types of lipids, 
omega three lipids, and other sorts that are  

2311
04:14:07,380 --> 04:14:14,340
also clearly in the Mediterranean diet that may be 
beneficial for these patients. But personally, if  

2312
04:14:14,340 --> 04:14:19,140
I have a patient that is highly inflamed, I just 
try to go very slow with this patient population.  

2313
04:14:19,140 --> 04:14:27,899
And I just try not to be too eager to reach 
the nutritional goals too fast. So typically,  

2314
04:14:27,899 --> 04:14:34,019
I would just start very slowly in these patients.
And typically, if the patient responds to whatever  

2315
04:14:34,020 --> 04:14:40,439
we do, if you give antibiotics or treatment, and 
typically we see that the inflammation will come  

2316
04:14:40,439 --> 04:14:46,620
down during the hospital stay. And so gradually 
we can then increase the nutritional intake.  

2317
04:14:46,620 --> 04:14:54,599
But this is just my personal view. I think the 
higher the inflammation, the more we have to be  

2318
04:14:54,600 --> 04:15:00,300
cautious and go slow with the nutrition just 
to prevent doing any harm to these patients.

2319
04:15:00,300 --> 04:15:06,660
DR. DAVID SERES: Yeah, I think we'll be talking about 
the Moonshot study that needs to be done. And  

2320
04:15:06,660 --> 04:15:12,059
one of the things I think that might come out 
of this would be to look...to see the trend if  

2321
04:15:12,060 --> 04:15:18,300
the C-reactive protein or other markers stay 
high, I would predict that those patients  

2322
04:15:18,300 --> 04:15:23,819
wouldn't respond as well to those who have a 
C-reactive protein that drops, because the ones  

2323
04:15:23,819 --> 04:15:28,559
who have the C-reactive protein that drops 
are getting medically better. So I would...  

2324
04:15:28,560 --> 04:15:32,686
yeah. Anyway, these are some of 
the really good questions that...

2325
04:15:32,686 --> 04:15:37,319
DR. PHILLIP SCHUETZ: It's very, interesting, and this 
is also new talk. I think it's very strongly  

2326
04:15:37,319 --> 04:15:43,620
correlated between also the severity 
of disease, response to treatment, and  

2327
04:15:43,620 --> 04:15:51,059
also response to nutrition. It's all kind of 
interacting to each other. And I don't think  

2328
04:15:51,060 --> 04:15:56,100
we have the perfect markers today. C-reactive 
protein may be one marker of inflammation,  

2329
04:15:56,100 --> 04:16:02,100
but there's maybe there's also other markers 
that can help us to understand if a patient is  

2330
04:16:02,100 --> 04:16:07,920
metabolically stressed, if he's ready to actually 
receive nutrition and what type of nutrition.

2331
04:16:07,920 --> 04:16:15,239
DR. DAVID SERES: And similarly, I think what Patrick was 
saying earlier is that we need to find some sort  

2332
04:16:15,239 --> 04:16:21,179
of a marker. And you were speaking specifically 
about the micronutrient levels and function,  

2333
04:16:21,180 --> 04:16:26,160
but in general markers that are 
not responsive to the disease,  

2334
04:16:26,160 --> 04:16:32,220
that can tell us whether or not we're 
nourishing adequately or not. And maybe  

2335
04:16:32,220 --> 04:16:43,199
those are far out there. But I think that's really 
what we're all hoping for would come. Let's see.  

2336
04:16:50,100 --> 04:16:57,960
So, Charlene, could you speak a little bit 
about, there were some questions before  

2337
04:16:57,960 --> 04:17:07,380
about the preference of ASPEN A&D, I mean, 
yeah, ASPEN A&D versus GLIM and so forth.  

2338
04:17:08,520 --> 04:17:12,900
Can you address the relationship between the two 
approaches just so that people can understand?

2339
04:17:14,160 --> 04:17:21,359
DR. CHARLENE COMPHER: Sure. It always amazes me when this 
question comes up, and it does come up regularly  

2340
04:17:21,359 --> 04:17:32,519
when I present about GLIM. GLIM was designed to 
be an umbrella that the SGA could fit under, the  

2341
04:17:32,520 --> 04:17:41,640
Academy ASPEN can fit under, the European approach 
can fit under. We're all using the same criteria.  

2342
04:17:42,960 --> 04:17:52,500
We needed not to have people walk away from 
the SGA if they have fully integrated the SGA  

2343
04:17:52,500 --> 04:18:04,260
into their medical system and it's in use. But we 
want to use GLIM as a common language so that we  

2344
04:18:04,260 --> 04:18:11,819
can make comparisons across the SGA, the Academy 
ASPEN, and all of the other approaches that are  

2345
04:18:11,819 --> 04:18:21,120
used. The same criteria are used, the same 
weight loss criteria are used for moderate  

2346
04:18:21,120 --> 04:18:34,559
and severe in most cases. In the U.S., we are 
not going to use low BMI as an identifier for  

2347
04:18:34,560 --> 04:18:41,880
undernutrition very frequently. Maybe 5% of 
our population has a low BMI. and we will see  

2348
04:18:41,880 --> 04:18:50,819
those in the hospital. But there are so much more 
going on with them that the fact that the Academy  

2349
04:18:50,819 --> 04:19:00,239
ASPEN does not have BMI and GLIM does is really 
a minor point. They're really one and the same 

2350
04:19:00,779 --> 04:19:05,460
and if you document one, you've 
essentially documented the other.

2351
04:19:08,279 --> 04:19:13,679
DR. DAVID SERES: I will also comment that, we 
were talking earlier about reimbursement  

2352
04:19:13,680 --> 04:19:19,979
for malnutrition that if there's not 
a low albumin below a certain level,  

2353
04:19:19,979 --> 04:19:25,679
it's my experience that most of the patients 
that we diagnose with severe malnutrition,  

2354
04:19:25,680 --> 04:19:30,900
unless they are not medically ill, are going to
have a low albumin. So I think that it's... 

2355
04:19:31,680 --> 04:19:42,239
because it's so prevalent that our patients 
are inflamed. Let's see. While we're talking  

2356
04:19:42,239 --> 04:19:50,279
to you Char, what do people mean when they're 
talking about nutrition-sensitive outcomes?

2357
04:19:52,560 --> 04:19:59,880
DR. CHARLENE COMPHER: I think that's an important question. 
And I'd like to say one more thing about outcomes  

2358
04:19:59,880 --> 04:20:07,140
after I address this question. I think Dr. Schuetz 
is trying to get at nutrition-sensitive outcomes.  

2359
04:20:07,140 --> 04:20:15,060
He's looking at the fact that the nutrition 
indicators are largely prognostic, but they  

2360
04:20:15,060 --> 04:20:24,661
don't predict the response to feeding, which 
from what he's shown so far, inflammation does.  

2361
04:20:26,580 --> 04:20:37,380
We look at outcomes of mortality because it's 
clear. We look at length of stay, and we look  

2362
04:20:37,380 --> 04:20:43,439
at re-admissions. We look at length of stay 
and re-admissions because they matter to the  

2363
04:20:43,439 --> 04:20:50,429
hospital's bottom line. If we have long lengths 
of stay, then some other patient can't come in  

2364
04:20:50,430 --> 04:20:59,819
to the hospital because the bed is not available. 
If we have re-admissions, we have to have the bed  

2365
04:20:59,819 --> 04:21:10,500
space. Those are outcomes that are of value to 
the overall system. They may mean much less to  

2366
04:21:10,500 --> 04:21:19,080
patients than, yes, they matter, mortality clearly 
matters to patients. But what matters to a patient  

2367
04:21:19,979 --> 04:21:28,439
about the quality of their life? What would make a 
difference to a patient in terms of his outcomes? 

2368
04:21:28,439 --> 04:21:33,899
I suspect that nutrition-related 
outcomes and feeding outcomes  

2369
04:21:35,580 --> 04:21:42,660
are going to be probably more 
diverse and more on the chronic level  

2370
04:21:44,460 --> 04:21:52,979
than mortality and length of stay and 
re-admissions. And the problem with looking  

2371
04:21:52,979 --> 04:22:00,779
at mortality in particular, in order to show 
differences in mortality, you need a massive  

2372
04:22:01,319 --> 04:22:08,699
sample size. For the other effort trial 
comparing protein dose In critically ill  

2373
04:22:08,699 --> 04:22:16,920
patients, we needed a sample size of 4,000 ICU 
patients to show a difference in mortality.  

2374
04:22:18,660 --> 04:22:26,699
When you need 4,000 patients, it's very hard to 
do the kind of sub analysis that Dr. Schuetz is  

2375
04:22:26,699 --> 04:22:32,160
talking about, finding the groups, the group 
of patients who benefited, the ones who didn't  

2376
04:22:32,160 --> 04:22:39,479
benefit, and the ones who had harm. It's also 
harder to enroll patients with malnutrition.  

2377
04:22:40,380 --> 04:22:49,140
It's hard to find, if only somewhere between 
20%, 40% of your population has malnutrition,  

2378
04:22:50,279 --> 04:22:57,300
how long is it going to take you to enroll a sample 
size of 4,000 so that you can determine whether  

2379
04:22:57,300 --> 04:23:03,359
there's a mortality difference or not? I 
think that we need to look at different,  

2380
04:23:03,359 --> 04:23:11,819
a broader array of clinical outcomes 
that are associated and see which ones  

2381
04:23:11,819 --> 04:23:17,880
are the ones that we can really use to know 
whether feeding made a difference or not.

2382
04:23:17,880 --> 04:23:25,739
DR. DAVID SERES: Yeah, I think that this is one of the 
really most important research questions is how  

2383
04:23:25,739 --> 04:23:32,219
do we measure the effect? Because really the 
only outcomes are mortality, quality of health  

2384
04:23:32,220 --> 04:23:37,979
or cost of health care, lengths of stay, things 
like that, complications, and quality of life,  

2385
04:23:37,979 --> 04:23:44,879
none of which are really easy to measure in 
smaller groups especially. But really are  

2386
04:23:44,880 --> 04:23:52,739
the things that matter. And all of our focus on 
surrogates to date...things like albumin and so  

2387
04:23:52,739 --> 04:23:59,819
forth...relate to outcome but don't relate to the 
nourishment. And so, we need to find that bridge, if  

2388
04:23:59,819 --> 04:24:10,739
we can for something that would take care of all 
of that. So we have just a couple of minutes left.  

2389
04:24:11,819 --> 04:24:23,399
There was a question for Patrick about inclusion 
of micronutrients in measures like GLIM and so  

2390
04:24:23,399 --> 04:24:26,739
forth. Any thoughts about that?
 

2391
04:24:30,239 --> 04:24:36,660
DR. PATRICK STOVER: Sure. It just goes back to points I made 
previously, and that is, can you classify  

2392
04:24:36,660 --> 04:24:44,099
the population based on a particular aspect of 
a disease state that would then inform whether  

2393
04:24:44,100 --> 04:24:51,180
or not they have a deficiency and if they are 
going to be responsive to increased exposure to that  

2394
04:24:51,180 --> 04:25:00,000
nutrient. And so, we don't have that right now. We 
do know, again, in particular patient populations,  

2395
04:25:00,000 --> 04:25:05,340
there are studies that have shown effects, 
but they haven't been done in a systematic  

2396
04:25:05,340 --> 04:25:09,120
way that really builds an evidence base for 
this. So, I mean, the two challenges are one,  

2397
04:25:09,120 --> 04:25:17,099
can we classify specific diseases or 
disease subtypes, two, alter nutrient  

2398
04:25:17,100 --> 04:25:24,180
needs? And that's really the challenge with, 
again, with the biomarker that you aspire to.

2399
04:25:24,180 --> 04:25:32,939
DR. DAVID SERES: Yeah, certainly. I know that I have 
certainly struggled with the term deficiency  

2400
04:25:32,939 --> 04:25:39,299
over the years because so many nutrients are 
altered by their disease. Critical illness,  

2401
04:25:39,300 --> 04:25:44,040
for instance, will lower your vitamin D level, 
but it's most likely because your vitamin D  

2402
04:25:44,040 --> 04:25:49,439
carrier protein drops, not because you have 
a deficiency. But if you look at the, well,  

2403
04:25:49,439 --> 04:25:56,219
there is a longer story to this, but there are 
now some 1400 papers on COVID and Vitamin D,  

2404
04:25:57,659 --> 04:26:03,359
all of the observational studies showing very 
strong relationships between D levels and outcomes  

2405
04:26:03,359 --> 04:26:09,059
with COVID, which only says that the sicker you 
are, the lower your D level is rather than the  

2406
04:26:09,060 --> 04:26:17,939
other way around. But suffice it to say that 
this is part of the reason for this session in  

2407
04:26:17,939 --> 04:26:25,199
particular about renaming malnutrition. Some years 
ago when Gordon Jensen got up to announce the new  

2408
04:26:25,199 --> 04:26:29,399
guidelines, I raised my hand in front 
of several hundred people. I said, "hey,  

2409
04:26:29,399 --> 04:26:34,620
Gordon, can we call it something else? Can we 
please call it Matilda? Because every time you  

2410
04:26:34,620 --> 04:26:39,300
say that a patient with malnutrition 
is malnourished, you might be wrong."

2411
04:26:40,859 --> 04:26:46,679
So ,on that note, I think we're about out 
of time. I want to thank everyone who has  

2412
04:26:46,680 --> 04:26:56,760
participated. Thank you all. We have a kudos 
in the question box. Thank you, Elizabeth, and  

2413
04:26:57,840 --> 04:27:04,260
look forward to tomorrow's session. We'll start off 
with a wrap-up of what happened today, and then  

2414
04:27:05,460 --> 04:27:11,340
we'll go into some of the talks that I mentioned 
about body composition and disease-specific  

2415
04:27:11,340 --> 04:27:20,340
cachexia studies to try and sort all of this 
out. And look forward to seeing you tomorrow.  

2416
04:27:22,620 --> 04:27:23,996
DR. PATRICK STOVER: Goodnight. Thank you.