DR. CHARLOTTE PRATT: Hello, my name is Charlotte Pratt, and I'm a Deputy Chief and Program Director at the
National Heart, Lung, and Blood Institute here at the National Institutes of Health. I co-chair
the Medical and Nutrition Implementation Working Group with Dr. Christopher Lynch,
and I am a member of the organizing committee for this workshop. Welcome. We are delighted
you are attending the Malnutrition in Clinical Settings, Research Gaps and Opportunities Workshop.
As Dr. Lynch mentioned in the welcome video, this workshop is hosted by the National Institutes
of Health Office of Nutrition Research and is relevant to one of the goals of the NIH
Strategic Plan for Nutrition Research. That is the goal to reduce the burden of diseases
in clinical settings. The overarching objective of the workshop is to identify
research gaps and opportunities to fulfill that goal. You have probably heard the quote,
"Let food be thy medicine," from Hippocrates, who is the father of medicine. This workshop has several
objectives to address the concept of food as medicine to curtail many chronic diseases.
These objectives include summarizing the state of the science and identifying knowledge gaps and
opportunities related to malnutrition in clinical settings; discussing research to understand,
measure, and address malnutrition in clinical settings; and identify ways to train and
increase the diversity of the clinical nutrition workforce to help close the health equity gap.
These objectives are very important because in a recent systematic review
by the Agency for Healthcare Research and Quality malnutrition among hospitalized patients remains
a serious issue, affecting more than 30% of hospitalized patients in the United States.
Malnutrition leads to high morbidity and mortality, functional decline,
prolonged hospital stays, and increased health care costs. Early identification and treatment
of malnutrition are critical to preventing poor health outcomes in hospitalized patients.
Proper screening and tools for accurate diagnosis and assessment are essential to identifying and
utilizing appropriate interventions. By addressing the workshop objectives,
including challenges faced with training the next generation of diverse nutrition workforce,
we hope to bring you much food for thought. Again, welcome, and thank you for attending this
workshop. I would like to introduce Dr. Griffin Rogers, Director for the National Institute of
Diabetes and Digestive and Kidney Diseases, who will also welcome you. Again, thank you very much.
DR. GRIFFIN ROGERS: Good morning. I'm Dr. Griffin Rogers, Director of the National Institute
of Diabetes and Digestive and Kidney Diseases, or NIDDK. I'm pleased to join with colleagues from
the Office of Nutrition Research and others at NIH, professional societies, and academic
partners in welcoming you to the kickoff of this NIH workshop on malnutrition in clinical settings.
As the institute funding the largest amount of nutrition research at NIH,
the NIDDK has a long-standing commitment to supporting researches that advances
understanding and clinical care of many chronic disease-related diseases within our mission.
This encompasses work on both overnutrition and undernutrition in terms of caloric and
micronutrient intake. We support research on the way the body absorbs and responds to
nutrients and how factors—such as disease, stress, drugs, toxins, the gut microbiome, and treatment,
such as bariatric surgery—affects the absorption and metabolism of nutrients. Malnutrition in
both adults and children, whether due to diet or disease, is one of NIDDK's research priorities.
The institute supports ongoing work by investigators across the country and abroad
to identify the factors at play at malnutrition and to develop innovative solutions. For example,
we've partnered with the Bill and Melinda Gates Foundation to support long-standing studies of
childhood malnutrition in Bangladesh and Malawi. These studies have identified the key role of the
gut microbiome and develop dietary supplements that boost microbial species needed for healthy
growth and development. Related to today's focus on adult malnutrition in the clinical setting, the
NIDDK funds research on malabsorption resulting from digestive diseases such as inflammatory bowel
disease, chronic pancreatitis and other forms of pancreatic disease, chronic liver disease,
chronic kidney disease, cystic fibrosis, and from weight loss procedures to treat obesity.
These studies are part of investigator-initiated projects, as well as larger efforts, such
as the Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer;
Gastroparesis Clinical Research Consortium; the Longitudinal Assessment of Bariatric Surgery;
cystic fibrosis research and translation centers;
HiLo study of people with kidney failure on dialysis; and a new Liver Cirrhosis Network.
Many of these efforts are done in partnership with other NIH institutes, patient organizations,
and private industry. The NIDDK also funds the Nutrition Obesity Research Centers Program,
a national research resource program that fosters interdisciplinary basic, clinical, translational,
and public health research related to nutrition and obesity. One of the NIDDK's guiding principles
is to foster a strong and inclusive scientific workforce through our many programs supporting
training and career development at each step of the career pathway. And you'll hear more later
in this workshop about the trans-NIH commitment to supporting training of a robust,
diverse, and inclusive research workforce. On our website, niddk.nih.gov, you can find information
about our research training programs as well as contact information or NIDDK program staff,
some of whom are participating in this workshop. They're always pleased to hear from members of
the scientific community with new ideas to share. And I encourage all researchers, especially those
just starting out, to contact them. Well, in addition to our research and training program,
the NIDDK provides health information in response to questions about nutrition and
weight management from health professionals and the public through its Health Information Center.
NIDDK is honored to be a part of this workshop, welcoming so many participants from the community
to join us in considering research-based solutions to address malnutrition. I look forward to hearing
the presentations and discussions to advance work on this very important topic. Thank you.
DR. GAIL CRESCI: Hello. My name is Gail Cresci, and I'm an associate professor in the Cleveland Clinic Lerner College
of Medicine of Case Western Reserve University and full staff in the departments of Pediatric
Gastroenterology and Inflammation and Immunity at the Cleveland Clinic in Cleveland, Ohio.
I am also the immediate past president of the American Society for Parenteral
and Enteral Nutrition. I am one of the medical nutrition implementation working group members.
Our working group members are leaders and represent the main clinical nutrition
societies in the United States—The American Society for Parenteral and Enteral Nutrition,
the Academy of Nutrition and Dietetics, and the American Society of Nutrition.
Along with the other working group members—Dr. Todd Rice of Vanderbilt University Medical Center;
Dr. David Sears, Columbia University Medical Center; Dr. Allison Steiber, Academy of Nutrition and
Dietetics and Dr. Nilesh Mehta, Boston Children's Hospital and Harvard Medical School—we are
honored and excited to have had the opportunity to plan this comprehensive workshop that addresses
the current status of clinical malnutrition from definition, its economic burden, its diagnosis,
biomarkers, and future potential interventions to future research opportunities and directions
to address the identified clinical gaps that we'll find throughout this workshop.
I now would like to introduce your moderator for Session One, Dr. Kelly Tappenden.
Dr. Kelly Tappenden received her Ph.D. in Nutrition and Metabolism at the University
of Alberta. And following postdoctoral training at The University of Texas Medical School in Houston,
she joined the faculty at the University of Illinois in Urbana and was there for
more than 15 years where she rose through the ranks from assistant to full professor.
Dr. Tappenden's current position is professor and head at the Department of Kinesiology
and Nutrition at the University of Illinois at Chicago. Dr. Tappenden's research program focuses
on intestinal failure, mechanisms regulating epithelial function, and patient malnutrition.
For these contributions, she has received multiple awards,
published over 100 peer-reviewed papers, and delivered over 500 invited lectures.
Dr. Tappenden served as the 33rd president for the American Society for Parenteral and Enteral Nutrition
in 2008/2009. She also was chair of Nutrition, Metabolism, and Obesity section of the American
Gastroenterology Association Institute from 2009 to 2013, and she was editor-in-chief of
the Journal for Parental and Enteral Nutrition, the scientific journal for ASPEN, from 2010 to 2022.
Dr. Tappenden currently represents the American Society for Nutrition on the Federation of
American Societies for Experimental Biology Board of Directors. Welcome, Dr. Tappenden.
DR. KELLY TAPPENDEN: Thank you, and welcome to our introductory session and Session One. We have
a very strong list of presenters set up for you today. First, for the introduction, Drs. Roman and
Jensen will provide an overview of malnutrition— both outside the hospital, highlighting community
issues, and then in the medical setting. We'll then move on to session one. The speakers will
provide an overview of the cost of malnutrition in the clinical setting. We will begin with the scope
of the problem and the cost of not addressing this important problem. So first Dr. Winkler, will
provide an overview of the AHRQ report. Then, Dr. Guenter will discuss the Value Project, Ms. Mitchell
will present on accelerating malnutrition quality of care through quality measurement
and finally, Dr. Kerr will follow and discuss the economics of nutrition and health care. So during
these sessions, please share your questions for the presenters in the chat box. What we're going
to do is try and address as many as we can in the question-and-answer session that follows live with
the presenters afterwards. So, here we go.
NANCY ROMAN: Morgan DiCesar was finishing up her freshman year at the University of
Minnesota in Spring 2010 when her vision started giving her trouble.
She thought late-night studying was causing it. But she went to the doctor who couldn't
find anything wrong with Morgan's eyes, but suggested she get a brain scan just to be safe.
The scan discovered a rare brain tumor that was growing rapidly, already impacting the nerves that
control eye movement. Her face was going numb. Her tumor was so advanced it could no longer be
treated with radiation. Yet new technology allowed her doctor to use microsurgical techniques to
remove it completely. She was in the hospital just 5 days. Her symptoms were gone in 1 week.
Les Baugh lost both of his arms at the shoulder during a horrible electrical accident when he
was a teenager. Two years ago, he got robotic arms that move according to his thoughts,
like any other. This arm has 26 joints, can curl up to 45 pounds. Wow. Advances in technology and
medicine are allowing us to cure disease and repair disability as never before.
As a nation and world, we've gotten very good at improving poor health or damaged bodies,
but we just aren't nearly as good at preventing health from going bad in the first place.
Accordingly, 100 million of us live with diabetes and pre-diabetes. More than 600,000 people—could
be us, could be our family members—will die of heart disease this year, and we're more likely to
get myeloma, colorectal, uterine, gallbladder, kidney, and pancreatic cancers than before.
Americans prize freedom so much, yet we're trapped in a food culture that's making us sick. Why,
when food can also make us well? My dear friend Nancy Mitchell burned her wrist badly, taking a
roasted chicken out of the oven. The roasting pan fell on her arm and seared the skin to the bone.
She went to Duke Burn Center, one of the top burn centers in the world. Now, she's a swimmer,
so her primary concern was how quickly would she be able to get back in the pool.
Her doctor treated the burn and then told her that from this point forward,
the single most important determinant in the speed of her healing would be what she ate—
lots of vegetables, only lean meat, plenty of protein. Her food would determine the
pace of her healing. We now know that food and nutrition determine a child's brain development.
Food determines the likelihood of getting diabetes, heart disease, and cancer. We have this
incredible burden of knowledge, and yet it's so very hard to respond to this burden of knowledge.
Why is that? Well, we're up against a lot when we try to eat smart. For one thing, we're up against
our very own taste buds. It turns out we're hardwired to crave salt, fat, and sugar. And if
you were a hunter-gatherer who stumbled on a honey tree, it would have served you to eat up all that
honey. And if you scored a kill, you would have lived longer had you eaten all the fat along with
the lean. Calories were scarce, and people were on the move. Sweetness came from fruit. Now it comes
from triple-stuffed Oreos, caramel lattes, added sugars, and everything. Not only do our taste buds
love salt, fat, and sugar, but when you compound our genetic predisposition with the power of food
marketing, and culture, it becomes near impossible to make better choices and to avoid bad ones.
So what do I mean? Let's take a look at the evolution of snacking foods from the turn of the
century through the agricultural revolution to the industrial area. In 1893, Cracker Jacks arrived,
and in 1900, the Hershey Bar. In 1912 came the Oreo, and Hostess cupcakes in 1919.
But up through this period, American life included so much more physical activity, and these foods
were infrequently consumed. They were treats in the truest sense of the word. The processed snack
food industry didn't shift into high gear until right after World War I when the stock market
boom gave rise to new snack foods and the leisure time to enjoy them. And so you see the quickening
pace of innovation with sugar, sodium, and fat that produces lots of delicious, not so great for
us food. The 20s gave us Eskimo pies, Girl Scout cookies, gummy bears, and my fave, Velveeta cheese.
The 30s, despite the Great Depression, brought Twinkies and Fritos, the 40s, Dairy Queen, M&Ms,
and Cheetos. But put on your seat belts, folks. Here come the 1950s; Dunkin Donuts, Oreida French
fries, Cheeze Whiz, and Pepperidge Farm cookies, Eggo waffles, TV dinners, KFC, refrigerated cookie
dough, ruffles. And this crescendo of junk food was our very own fault. America's food companies
gave consumers exactly what we asked for: quick, convenient, tasty food at good prices.
But in so doing, without attention to how salt, fat, and sugar are tied to our health,
these very foods helped create our broken food culture. The broken food culture, of course,
leads to our sick patients, neighbors, families, and friends. The national adult obesity rate is
up 26% just since 2008. So now more than 40% of adults and 20% of children between the age
of 2 and 19 in the United States live with this condition and associated diseases. And
if you're low income, it's more likely to be you because there's such a strong link between food
insecurity and all ten of the chronic diseases measured by the CDC-hypertension, coronary heart
disease, hepatitis, stroke, cancer, asthma, diabetes, arthritis, COPD, and kidney disease.
Now some of you have or will encounter these patients in the clinical setting.
Others are doing research meant to inform the clinical setting. I come to this discussion after
two decades in the hunger and malnutrition sphere. First, at the United Nations World Food Program,
the world's largest humanitarian agency providing food to 100 million people in 75 countries,
mostly in emergency settings. There, we were... most often encountered malnutrition in the
form of undernutrition, and it wasn't easy to look at. On a trip to Ethiopia in 2008
when I joined a team assessing impact of drought on health and nutrition,
I saw a man collapse and die from starvation as he approached one of our hunger clinics.
In Haiti, a woman once begged me to take her baby because she could no longer feed him.
In those heartbreaking situations, people suffered from a life-draining lack of both calories and
nutrients that is visible and easy to understand. Too little food equals too little nutrition.
So it was an adjustment to return to the United States and begin to understand the malnutrition
here aided and abetted by our culture full of junk food where calories are plentiful,
but nutrition can be in short supply. I saw the effects of this kind of
malnutrition up close and personal as head of the Capital Area Food Bank, serving 500,000 people in
greater Washington, DC. There, we worked with and for a malnourished population that often showed up
as overweight people. Salty, fatty, calorie-laden diets lacked the nutrition they needed to build
health but had more calories than would allow them to maintain a healthy weight. It's critical to
understand that while people in the United States may not be collapsing from a lack of calories and
energy, the onset of and/or aggravation of the many chronic diseases mentioned above
are diminishing the lives of millions needlessly right now, right here in the United States.
A whopping 53.6 million people live in low-income, low-access communities more than 10 miles from
any grocery store. That's one of six of every one of our fellow citizens. It's not only harder for
them to get good food, but harder for them to work their way out of this health-diminishing
food trap because of place-based realities we call the social determinants of health.
How can we fail to use food as a tool for health when our broken food culture is either the driver
of or the result of all five determinants of health? Let's consider them. Number one; Economic Stability.
Economic instability clearly drives food insecurity. We know those who struggle
to make ends meet, cut meals and default to the cheapest fast foods and processed carbs.
Two, education. Lack of good food certainly undermines education. We
know that when you're hungry, it's hard to pay attention in school to learn or even to think.
Number three; Health and Health Care. The health system has so far failed to acknowledge poor food
as a prime driver of poor health or, more frustratingly, to leverage good food as a
tool to improve health. It has failed to require sufficient hours of nutrition education as part
of med student curricula, leaving intelligent doctors much less informed and knowledgeable
than they should be about food as a factor in their patients' conditions or food as medicine.
Number four; Neighborhood and Built Environment. We know built environment and low-income areas
feature fast food on every corner and precious little access to vegetables
and other whole food. You won't find a Sweetgreen or a Whole Foods in Ward 8,
Washington, DC, or any other under-resourced neighborhood. Number five; Social and Community
Context. The social events and family culture in under-resourced communities are high in salty,
fatty diets and fast food that dominates the built environment. And if you aren't persuaded yet,
let's consider what this broken food culture is costing in dollars and cents. Adults struggling
with obesity spend 42 percent more on direct health care expenses than peers at a healthy weight.
75 percent of all U.S. health care spending is spent on patients with one or more chronic conditions.
We spend $300 billion treating heart disease every year and $327 billion treating diabetes, so the
food culture we're trapped in is costing $1.3 billion per year and direct and indirect costs.
Yet what surprises me most is our stunning failure to respond to this incredible burden of knowledge.
Are we really trapped? Why do we accept this?
Because we have understood our broken food culture as something that cannot change.
We see the broken food culture as water to a fish— the immutable environment. In fact, our broken
food culture is not immutable. It can change. It must change, and we must be the ones to change it.
Fortunately, I'm not alone in thinking this way, and I will close with four signs of hope.
One, leadership truly matters and we are beginning to see some. Dr. Agnes Kalibata, who led the UN Food
System Summit to success last year, which spawned global activity around the world,
including right here in the United States, where the Biden administration is stepping up with the
coming White House Conference on Nutrition, September 28. The World Economic Forum,
as an outcome of that effort, worked with 80 global food companies to consider why
the food system produces so much unhealthy food. And they've concluded that public health has just
been too low on the corporate agenda. So look for that to begin to change as leaders step up.
Number two; innovation. In my role at PHA, we are often approached by entrepreneurs working
on new models aimed at getting high-quality food to lower-income customers—a real challenge.
Both the number of entrepreneurs and the quality of their ideas are improving.
Number three, the next generation gets it. Young food leaders from 37 countries gathered for the
Food System Summit last year. They ranked the many issues dogging the food system, from lack of soil
health to low wages for farmers. Their number one issue was healthy food for all. "We want
to ensure that everyone everywhere has access to healthy, sustainable, and resilient food."
And finally, number four; There's some really smart non-profit work catalyzing
change, and I'll describe ours. At PHA, we're building a food equity movement. As part of that,
we're equipping pediatricians with information about the importance of vegetables in the diets
of infants and children and tips on how to introduce them...to young parents,
so we set up a generation with healthy eating habits.
We've designed a Good Food for All produce program that distributes vegetables and fruits
through a saturation model. Families receive two servings of produce per day, per person,
7 days a week for 12 successive weeks. Our data shows that a fruit habit is established by
week 7 and a vegetable habit between weeks 10 and 12. These are powerful findings to build on.
And we're piloting the sale of plant-forward meal kits that compete with fast food in price and
taste. We must offer alternatives to the built food environment in low-income communities. So
these are a few steps for others to build on. In short, while our own desire for quick, tasty,
long-shelf-life foods helped build this broken food culture we've been trapped in for 50 years,
we are finally beginning to understand that it doesn't have to be this way.
Can we finally respond to the mounting burden of knowledge? If enough of us decide to make a better
food culture a United States priority, I'm confident that we can step by step,
rebuild our broken food culture, prevent a heck of a lot of disease, and live much better lives.
Thank you.
DR. GORDON JENSEN: This is Gordon Jensen. I'm going to share a presentation with you that is an overview
in the medical setting regarding disease-related malnutrition. I'm the Senior Associate Dean for
Research Emeritus at the Robert Larner College of Medicine at The University of Vermont.
My objectives for this 20-minute overview is to talk a bit about where we have been,
provide a historical perspective, then shift to where we are now in regard to
evolving approaches to screening, assessment, diagnosis, intervention, and monitoring, and
with particular focus on the contributions of disease and inflammation, and wrap up by
talking about where we are going with key questions and research priorities.
So historical background, I'll really start with Jonathan Rhoads, who was the son of a Quaker
physician. He attended Haverford College and completed his M.D. at Johns Hopkins.
At the University of Pennsylvania, he served as the Chair of Surgery and Provost, and he was a
renowned researcher, scholar, and medical leader. And he pioneered the development of intravenous
feeding, working with Stan Dudrick and Doug Wilmore on landmark studies in dogs and then
in humans. And I had the pleasure of having dinner some years ago with Jonathan Rhoads,
and he was sharing stories with me of his early research studies, really a very exciting visit.
Other pioneers that helped to set the stage included Hiram Studley, who studied the
percentage of weight loss as a basic indicator of surgical risk in patients with chronic peptic
ulcer disease, with this landmark paper in JAMA in 1936. There are also some of my mentors,
Bruce Bistrian and George Blackburn at Harvard, that looked at the prevalence of malnutrition
in general surgical patients and general medical patients, and these two renowned
JAMA presentations—papers from the 1970s. Other pioneers included John Waterlow and his classic
paper on Classification and Definition of Protein Calorie Malnutrition in 1972; Charles Butterworth
in his paper entitled "The Skeleton in the Hospital Closet", which was really a call to action
highlighting the high prevalence of malnutrition in hospital settings published in 1974;
and then Khursheed. Jeejeebhoy, still very much with us, very active, was the pioneer behind
subjective global assessment that included metabolic stress as a disease component in
assessment. Well, the settings for malnutrition across the globe have continued to evolve over
time, and historically, famine and starvation were quite prevalent. There were also, you know,
environmental catastrophes and wars. But today, we really face multiple burdens. Famine and
starvation are still very much with us, but war and genocide continue, with food deprivation as a
weapon, and malnutrition in the setting of disease or injury is now very prevalent across the globe.
So malnutrition now encompasses the full spectrum of undernutrition and overnutrition.
These two individuals shown on this slide are both malnourished, one with a profound
temporal wasting and muscle loss, very severe undernutrition. The other patient with significant
overnutrition, but is also malnourished with multiple micronutrient deficiencies.
And we continue to have difficulties with refugees and displaced persons being at high risk for food
insecurity and malnutrition. And the UN Refugee Agency in 2020 estimated that 82 million people
have been forcibly displaced. And currently, and the war in Ukraine, more than 12 million
people have had to flee their homes. So these very concerning issues continue. And of course,
most recently, we have had the COVID-19 pandemic associated with food insecurity and malnutrition.
Feeding America estimated that some 17 million Americans would become food insecure during the
pandemic. And of course, there are issues with distancing, lockdowns, quarantines,
supply chain, loss of employment, cost of food. And these issues very much continue
today. And food insecurity and malnutrition are associated with the chronic diseases that place
people at higher risk for severe complications of COVID-19. And a high prevalence of malnutrition
is found among hospitalized COVID-19 patients and is associated with increased mortality.
The limitations of our historic approaches to thinking about diagnosis of malnutrition
include use of criteria that lack full validity, limitations and specificity,
sensitivity and inter-observer reliability, overlapping definitions of misdiagnosis, multiple
definitions resulting in widespread confusion, and lack of a modern appreciation for the role
of the inflammatory response. New insights over the past two decades include an understanding
that the pathophysiology of malnutrition that is associated with disease or injury invariably
consists of a combination of varying degrees of under or overnutrition and acute or chronic
inflammation, leading to altered body composition and diminished biological function. In addition,
disease-related malnutrition has been defined as the point at which the severity or persistence
of inflammation results in a decrease in lean body mass associated with functional impairment.
Disease-related malnutrition is associated with a host of poor outcomes, including increased
mortality, increased complications, increased length of hospital stay, increased health care
cost, and poor quality of life. And thinking about this in a more
expanded way, one can consider inflammation as an adaptive physiologic response versus
self-destruction. And over the short run, indeed, inflammatory response can be quite adaptive to
survive severe infections to mount the necessary response to get through a catastrophic injury. But
when inflammation is sustained or severe, that is very much associated with adverse outcomes.
And disease-associated inflammation promotes malnutrition and adverse outcomes. It promotes
poor appetite, decreased nutrient intake, alters metabolism with elevated resting
energy expenditure, and muscle catabolism with increased nitrogen excretion. It also results in
altered micronutrient status and requirements. Some examples include iron, zinc, selenium,
vitamin D, and vitamin A, but there are others. It also blunts the response to our nutrition
interventions and makes them less efficacious. There's an interesting story I wanted to share
with you from Merker and colleagues published in JAMA in Network Open in 2020, where they looked
at the Association of Baseline Inflammation with the Effectiveness of Nutritional Support
Among Patients with Disease-Related Malnutrition. It was a secondary analysis of a randomized trial
looking at early nutrition support on outcomes that included frailty, function, and recovery in
eight Swiss hospitals, nearly 2,000 participants, all of whom had an admitting C-reactive protein.
Compared to controls, those that received nutritional support had a significant reduction
in 30-day mortality, regardless of CRP level. However, when you looked at people with very
high inflammatory state, there was no beneficial effect of nutritional support on 30-day mortality.
So, there's been a really robust effort to enhance diagnosis and characterization of malnutrition.
There are several leading approaches available now that are in widespread use across the globe for
diagnosing and evaluating malnutrition, including subjective global assessment. The Academy—ASPEN
Indicators for Malnutrition, and the Global Leadership Initiative in Malnutrition. These are
in widespread use across the globe, often subject to regional preferences and established usage.
And you'll hear more about these throughout the three day workshop.
Diagnosis can be related to underlying ideology, and this turns out to be fundamentally of
importance. So you can consider malnutrition related to chronic disease with inflammation,
malnutrition related to chronic disease of minimal or no perceived inflammation, malnutrition
related to acute disease or injury with severe inflammation, and starvation related to hunger
or food shortages associated with socioeconomic or environmental factors. Is it possible that
we can use conditions that are associated with inflammation as proxy indicators for inflammation?
This is something we are actively evaluating. So, you know, typical disorders associated with
severe acute inflammatory response include critical illness, major infection or sepsis,
ARDS, SIRS, severe burns, major abdominal surgery, multi-trauma, and closed head injury. More mild to
moderate chronic inflammatory response can be associated with cardiovascular disease,
congestive heart failure, COPD, Crohn's disease, diabetes, metabolic syndrome, dementia,
and a host of other diseases or conditions. If this approach was to work, it would
require a relatively straightforward clinical recognition of the underlying disorder. Of course,
it may suffer with issues in terms of sensitivity and specificity. Potential laboratory markers of
inflammation certainly include C-reactive protein, which is perhaps the most used marker, but also
interleukin six and procalcitonin. And indeed what were historically considered to be markers
of protein malnutrition, albumin or prealbumin, are negative acute-phase reactants that are involved during
inflammatory states. Immune dysfunction is another consideration, metabolic phenotyping, but there
is a desperate need for improved laboratory markers of both malnutrition and inflammation.
Other supporting assessments can include body composition, revealing decreased muscle mass;
indirect calorimetry, revealing elevated resting energy expenditure; and clinical assessment,
including fever, hypothermia, tachycardia, signs of muscle loss, and presence of edema. The
key observation here is that nutrition support by itself in the study of robust active inflammation
is not going to obviate a poor outcome. It requires treatment of the underlying
condition disorder or inflammatory state combined with nutrition care.
There's interest in a host of potential interventions for inflammation, including
anti-inflammatory medications; anti-cytokines; enhanced glycemic control; nutrition modulators,
of course of particular interest to this audience; including n3 fatty acids; antioxidants; bioactive
food components or modified diets; caloric restriction, and enteral preferred over parenteral
nutrition support. There's also probiotics and also physical activity and weight loss.
So conclusions to take away from my short overview would be that malnutrition in the setting of
disease is different. Two, disease-related malnutrition is common in health care and
other settings. Three, that disease-related malnutrition is associated with poor medical
treatment outcomes. And four, that disease related malnutrition requires both treatment of underlying
disease and nutrition intervention. And to wrap up with some quick comments
regarding research priorities and questions, number one, can we fully integrate screening,
assessment, intervention, and monitoring to promote improved outcomes? At present,
it is very common for these not to be integrated in a meaningful intervention, especially with the
transitions to outside-of-hospital care. Can we develop standardized approaches to diagnosis and
data reporting so that we can compare prevalence of malnutrition, as well as interventions and
associated outcomes? Can we better train practitioners? I think in particular there
is a priority to develop a validated approach to diagnosis that incorporates key core variables
that are amenable to use by practitioners with limited nutrition expertise or resources. An
example of an approach in this direction would be the Global Leadership Initiative in Malnutrition.
And there also should be opportunity for a streamlined hybrid approach to integrate screening
and assessment components for a preliminary of diagnosis of malnutrition. And in settings where
feasible, this should trigger comprehensive assessment, promoting better integration.
Some additional priorities and questions. Biomarker panels are needed to support
diagnosis and monitoring of undernutrition and inflammation. Technology development is needed
to provide portable, valid, reliable, inexpensive assessment of muscle mass and function that is
applicable to diverse care settings. Appropriate and useful outcome measures are needed. Mortality,
length of stay, complications, and readmission are complex multivariable outcomes that are impacted
by many other variables besides nutritional status. Now, is there potential to develop
tailored population-level and disease-specific interventions? These warrant further evaluations,
and to begin with, we should probably focus our initial research efforts on those types
of patients that we believe are most likely to accrue benefits from such nutritional
support. And I thank you for your attention, and I'm looking forward to an exciting series
of presentations throughout the workshop over these 3 days. Have a great day.
DR. MARION WINKLER: My name is Marion Winkler. The objective of my presentation today is to provide an overview of
the Agency for Healthcare Research and Quality Report on Malnutrition in Hospitalized Adults.
Congress requested in fiscal year 2020 that the Agency for Healthcare Research and Quality convene
a panel of experts charged with developing quality measures for malnutrition-related readmissions.
These measures were intended to support assigning accountability for the assessment and treatment
of malnutrition in hospitalized adults, with an emphasis on the needs of older, frail adults.
The Evidence Practice Center worked with a panel of technical and content experts, some of whom
are speaking at this virtual conference. The final evidence report underwent simultaneous
independent peer review and public comment. And my role in this project was as a peer reviewer.
The investigators conducted a systematic review of research published between January 1, 2000,
and June 3, 2021. Using predefined criteria focused on adults aged 18 years or older,
the search did include existing systematic reviews that assessed associations between
malnutrition and clinical outcomes, randomized and nonrandomized studies
evaluating the effectiveness of screening or diagnostic nutrition assessment on clinical
outcomes, and RCTs assessing hospital- initiated treatments for malnutrition.
Meta-analyses were conducted when appropriate to quantitatively summarize study findings,
otherwise, the data were narratively synthesized. And when available, pooled estimates from existing
systematic reviews were also used to determine association between malnutrition and clinical
outcomes, as well as to assess the strength of evidence. All of the data synthesis was performed
using the AHRQ Methods Guide for Effectiveness and Comparative Effectiveness Reviews.
Malnutrition was defined based on common diagnostic tools, such as SGA or MNA,
and the screening tools, such as the Geriatric Nutritional Risk Index, the Malnutrition Universal
Screening Tool, and the NRS-2002. Interventions of interest included treatments initiated within
hospital and intended to impact nutritional status, such as specialized nutrition care, which was
described as referral to a registered dietitian or consultation with a nutrition specialist,
as well as increased protein and calorie provision through oral nutrition supplementation,
energy-dense supplements or fortified meals. The studies did not include enteral or parenteral
nutrition, primarily because these intervention trials did not define diet malnutrition using a
common diagnostic assessment tool. The clinical outcomes of interest included mortality,
length of hospital stay, 30-day readmission, quality of life, functional status, activities
of daily living, hospital-acquired conditions, wound healing, and discharge disposition.
There were three key questions addressed. Key question number one, what is the association
between malnutrition and clinical outcomes among hospitalized patients? Key question two,
what is the effectiveness of screening or diagnostic assessment for malnutrition?
And key question three, among patients diagnosed with malnutrition, what is the
effectiveness of hospital-initiated interventions to treat malnutrition?
In this study flow diagram, you can see that the electronic searches identified 3,308 citations,
of which 83 required full-text review. Overall, 17 studies met the eligibility criteria for
inclusion, including six systematic reviews to address key question one.
There were no studies that met the inclusion criteria to address key question two, that's
the effectiveness of screening on hospitalized adults. And there were 11 RCTs included to answer
key question three regarding the effectiveness of interventions used to treat malnutrition.
The primary reasons for exclusion related to wrong patient population not being hospitalized,
lack of definition or diagnosis of malnutrition with an appropriate tool,
study design or the wrong geographical setting. And most of the studies in the systematic
reviews were prospective cohort trials, and the patients were hospitalized for traumatic injury,
acute medical conditions requiring ICU level of care, heart failure, cancer,
COPD, and cirrhosis awaiting liver transplantation.
Now, the findings for...to answer key question one, which was the association between malnutrition
and clinical outcomes...in general, the findings included that ICU patients screened or diagnosed
with malnutrition may have higher hospital mortality compared to well-nourished patients.
Malnutrition was independently associated with prolonged hospital length of stay among patients
with acute medical conditions or cancer, and that malnutrition was associated with increased
hospital-acquired conditions among patients with trauma or acute medical conditions compared to
well-nourished patients. And you can see the overall standard of the evidence being low.
As mentioned earlier regarding key question two in terms of clinical utility or effectiveness
of screening, there were no studies included. They lacked...they did not meet the inclusion criteria.
And the primary reason was the lack of an appropriate control group. Regarding key question
three the effectiveness of hospital-initiated malnutrition interventions compared to usual care,
these interventions, likely decrease mortality and may actually improve quality of life,
which was measured by the EuroQol or the Short Form 36. There was no difference observed between
interventions and usual care for length of stay, readmission rates, or hospital acquired conditions,
and evidence was insufficient to address effect of interventions on activities of daily living
and discharge disposition compared to usual care. So overall, the review confirmed that malnutrition
defined by commonly available measurement tools is associated with poor clinical outcomes. And
the review found no studies to assess whether malnutrition, screening, or diagnostic assessment
actually prompts actions that change either nutritional stores or these key clinical outcomes
of interest. The review did find moderate evidence from 11 RCTs that hospital-initiated specialized
nutrition care and increased protein calorie provision likely reduces mortality compared to
usual care and may improve quality of life. The review does, however, underscore the many known
limitations of research on nutritional measurement tools, including the very definitions of
malnutrition and reliance on disease, weight loss, body mass index, and other biomarkers, such as serum
albumin, as proxies for malnutrition, diagnosis, or clinical opinion to define malnutrition.
There were also very few studies that aligned with the Global Leadership Initiative on Malnutrition,
the GLIM consensus criteria, although this likely relates to the time frame that was studied.
Overall, the review acknowledges the known variation in measurement tools regarding
validity and reliability. And finally, there was a high risk of bias and poor reporting
of adverse events in the intervention trials. Well, the Agency for Healthcare Research and
Quality Report on Malnutrition in Hospitalized Adults identified a number of clinical practice,
knowledge, and research gaps. And the authors highlight a gold standard is
really necessary to support future clinical care and research for defining malnutrition.
Future studies should stratify patients by age, gender, and frailty. And the absence of studies
addressing the clinical utility or effectiveness of measurement tools for both nutrition screening
and diagnostic assessment does not imply that these tools are ineffective. Rather,
it reveals the need for appropriately designed studies to better understand the downstream
consequences of screening, assessment, management, and clinical outcomes, specifically because of the
hospital mandate in the United States to screen for nutrition risk within 24 hours of admission.
Now, future research should also support the identification of which variables in
the measurement tools have the greatest impact on sensitivity and specificity in prospective
clinical trials, and future studies should also randomize patients diagnosed with malnutrition
to different interventions, including parenteral and enteral nutrition, and do subgroup analysis to
assess the benefits of nutritional intervention and document harms associated with treatment.
And finally, further research in this area is essential to determine which malnourished
patient populations benefit from specific types of interventions, and key guidance for hospitals is
needed to standardize the processes for screening, diagnosing, and documenting malnutrition in order
to inform development of quality measures and improved patient outcomes. Thank you.
DR. PEGGI GUENTER: Good afternoon. My name is Peggi Guenter from the American Society for Parenteral
and Enteral Nutrition. And today I will be speaking to you about the ASPEN Value Project.
We know that health care leaders are looking for guidance on prudent investment in
programs and resources that improve the patient experience, reduce hospital acquired conditions,
reduce length of stay, and decrease readmissions. In 2017, ASPEN projected the need to expand our
role from an organization promoting utilization of specialty nutrition services to one that also
clearly was articulating the value proposition for nutrition support across the continuum.
This project meets several of those goals of our strategic plan.
The goals of the value project were to describe the impact of nutrition care, particularly related
to specific conditions on health care costs and resource utilization, to provide economic
evidence to demonstrate the impact nutrition has on patient outcomes in specific therapeutic areas,
and to provide ASPEN members and stakeholders more effective messaging to communicate
with key health care decision-makers, such as administrators, providers, payers, and regulators.
Our plan for this project came in three parts, and for this we partnered with
Avalere Health. Part one was the nutrition care outcomes targeted literature review.
Part two, the analysis of cost data using Medicare claims.
And three, development of the value messaging for the top five to eight impact conditions.
So for part one, our approach was conducting a targeted literature review. And for that,
we used publicly available evidence through April of 2018. That literature should be reflective of
the impact of nutrition care on patient clinical and cost outcomes. It should include high-impact
conditions in all care settings. And also, we used general nutrition care search terms and
disease-specific search terms as directed by the ASPEN Scientific Advisory Council.
Our overall results from that literature search were that there was high variability
in the quality of evidence, and most study endpoints focused solely on clinical outcomes.
Specifically, the literature consisted of mostly moderate-quality evidence.
Over 70% of the articles reported were only clinical outcomes. Over
70% of the articles assessed oral nutrition supplements, enteral and
parenteral interventions. And about 75% of the articles reported studies at a single site.
We found there were only five level-one grade articles that were based in the United States.
So from this, the Value Project Scientific Advisory Council examined eight top therapeutic
areas to select five for our part two or the Medicare analysis. Our questions were which
ones are homogeneous and could be analyzed, which could be most impactful, and which ones already had
some claims data research? So from the literature, we came up with five for the Medicare claims that
was pancreatitis, sepsis, GI cancer, hospital-acquired conditions, and surgical complications.
So we started with 1,099 studies. In the 13 original therapeutic areas, we found 114
papers that had clinical and/or cost outcomes measured. In the eight selected therapeutic
areas with literature that was evaluated to be strong, we narrowed that down to 81 studies.
Then in the five therapeutic areas, we found 43 studies, then removed many due to the following
factors and ended up with eight studies to use for part two. Some of the reasons
to remove studies were that the factors may not have been observable or measurable in the
Medicare database; that the study compared several different interventions; such as EN versus PN;
that they were duplicative of other studies; or that they were not focused on an intervention.
So our objective of part two is to understand the real-world cost
impacts of nutrition care services in the five selected therapeutic areas.
We wanted to identify the maximum amount of savings to the Medicare program
based on modeling findings described in those studies. Our studies included in part one were
assessed for feasibility of modeling their reported outcomes onto Medicare Part A and B
claims and for those where study components could be modeled, annualized savings were projected.
We were using ICD-10 codes to identify the study populations and assign conditions.
And we are applying the study results and extrapolating cost savings. For each included
study, applying findings to the defined population and measuring savings associated with reduced
adverse outcomes or research utilization, such as a lower length of stay or reduced complications.
So we utilize the Medicare fee-for- service Parts A and B claims the
5% sample database. The 5% sample, as is known...is recognized as being
statistically representative of the entire Medicare population and could be roughly
adjusted to the full 100% population by multiplying raw results by 20.
Sample database include costs from inpatient and post-acute care. And then, once the savings were
calculated based on the raw sample data, the results were adjusted to the full population
and further adjusted the results to describe the average annual effects of the intervention.
So here is an example of how we did the modeling based on one study in septic patients with ARDS
on the ventilator and on enteral nutrition. We pulled 33 months of Medicare 5% sample
from October 2015 to June of 2018. Using ICD-10 codes, we limited it to patients with these
conditions who are also receiving tube feeding. And we found 309 patients who met these criteria.
We then applied the study results. For instance, in this study it was reported
a 38% reduction of length of stay. And with 309 cases, we found average about nine cases
per month in that 5% sample. The cost savings of that potential decreased length of stay—
$23,000 per patient—was applied to the nine patients per month, yielding $215,000 for all
nine patients. We then multiply it by 12 to get the annual savings, which was about $2.58 million.
We then extrapolated that 5% sample to 100%, and that went up to $52 million in annual savings.
This is a reflection of the upper limits of possible savings to Medicare in a year if
the length of stay could be reduced in all these possible patients that met the study criteria.
So what we ended up with looking at sepsis, GI cancer, hospital-acquired conditions, and
surgical complications was an applicable cost reduction of about $582 million.
Some of these studies were looking at different outcomes,
and so that's where we got the different studies with the different cost savings.
Here is our report published in the 2020 Journal of Parenteral and Enteral Nutrition on the findings
of this project. We also had the data pulled on coded malnutrition in these patients. You can see,
for instance, based on a study of esophageal cancer patients and surgery, there were 8,179
patients in the Medicare database. Twenty-one percent had a coded diagnosis of malnutrition. And of those, only 15%
received enteral nutrition. These malnutrition rates range from 14 to 30%, and yet only 2 to 16%
of those with malnutrition received nutrition support. This again shows the need for better
diagnosing and coding malnutrition and appropriate application of nutrition support interventions.
The Value Project Work Group published an additional two papers, one on GI cancer data
by Dr. Pimiento and one on hospital-acquired infection analysis by Dr. Matt Bechtold.
Looking to future research, one thing was clear from this project
was there are not enough studies that look at value and financial
implications of nutrition support with their impact...its impact on outcome.
A few learnings that we suggest be included in the future research are;
use of homogeneous patient populations, report the cost of nutrition support services,
produce evidence around net savings in terms of health care costs, collect and report data on
reductions in readmissions or complication avoidance as a outcome to show value,
and explicitly capture information on malnutrition diagnosis to better
characterize the incremental value of treating this subpopulation.
Partial funding for the ASPEN Value Project was supported by these industry partners.
Here are my references, and thank you so much for the opportunity to speak with you on this topic.
DR. KRISTI MITCHELL: Good afternoon. Thank you again for the opportunity to share
the development of the Malnutrition Quality Improvement Initiative,
also known as the MQii, interesting findings from our data and how such an initiative can
accelerate optimal malnutrition quality of care both in and outside of the acute care setting.
During today's presentation, I will briefly walk you through the MQii,
our experience in quality measure development and adoption, and I'll outline how it has served
as the foundation for driving malnutrition quality of care across hospitals throughout
the country. I look forward to sharing some lessons learned from our research over the
last few years and then tee up what's next on the horizon for this national initiative.
Finally, I want to lift up for consideration future research opportunities to expand on
evidence base and potentially close some knowledge gaps in the space.
As with all presentations about malnutrition, there is a need to level set around why it
matters. With this audience, I don't need to go into the details presented on this slide,
but to state that the ground has been set for the need to raise
awareness and implement interventions to advance evidence-based, high-quality,
patient-driven care for hospitalized older adults who are malnourished.
To answer this call for action, in 2013, the Academy of Nutrition and Dietetics,
along with Avalere Health and other stakeholders, developed and implemented the MQii as a national
QI program. I am fortunate to have been involved with this initiative since its inception.
Our aim has been to improve care and outcomes for hospitalized adults aged 65 and older
with a series of nutrition-focused QI innovations,
including the development of an interdisciplinary QI toolkit that's available online for anyone to
use. Two, the establishment of a national Learning Collaborative. And three,
the development of the first set of malnutrition electronic clinical quality measures or eCQMs.
We provided this dual-pronged approach, largely based upon feedback from the hospital community,
begging for no new measures without providing tools to help them improve.
As the crown jewel of our initiative, we launched the Learning Collaborative with seven
participating hospitals in 2015. It has since expanded to a 314-member network across the U.S.
located in 38 states and Puerto Rico, representing dozens of health systems.
There has been a tremendous groundswell of support across the U.S. that has catapulted us
towards success. Of note, interest in engaging in this initiative has spread globally.
In 2018, we answered a call from the National Health Service to adopt the toolkit and our
quality measures across a number of health trusts in the U.K. What a great testament to
the power of this approach. More importantly, what a unique research opportunity to compare
and contrast clinical performance against a standardized set of quality measures.
Measurement overall is necessary if you truly seek to improve.
As Peter Drucker would say, "If you can't measure it you can't manage it."
On this slide, you will see that it's taken quite some time to develop, test, receive endorsement
from the National Quality Forum, and finally gain national adoption into a CMS reporting program.
This road has been bumpy, but it has certainly paid off. At the end of this journey, we now have
four individual eCQMs that mirror the nutrition care process and one new global composite measure
that has been adopted by CMS for inclusion in its inpatient quality reporting program.
So what does this all mean? What is this composite score? I want to quickly call your attention to
the four components of the global malnutrition composite score and highlight that it is indeed
the first electronic global measure that's ever been adopted by CMS for accountability. That is,
hospitals can voluntarily select this measure to meet their requirement for value-based
reimbursement. We see this as a huge win for the community and an even bigger win for patients.
While we were moving quality measurement along on the national level, 90 plus
hospitals participated in routinely capturing the same for eCQMs screening, assessment,
diagnosis, and the establishment of a care plan on a local level. Upon sending us their data, we
provided these hospitals with quarterly benchmark reports for them to track and monitor their own
performance against their peers. To date, we have well over 1.5 million patient records
detailing nutrition care and have published well over 30 papers about our experience to date.
Of note, one paper published in JPEN in 2021 detailed the experience of 27 hospitals
participating in the MQii. Multivariate analysis were conducted across 43,000 unique patients,
and improvements were observed across all four of those eCQMs. The greatest improvement was
in timely nutrition assessment and malnutrition diagnosis. Most notably, patients over 65 with
a malnutrition diagnosis and a care plan had a 24% lower likelihood of 30-day readmission.
But the same population had a longer mean length of stay than those who did not have a care plan.
Overall, we found that the implementation of the MQii practices significantly improved
the identification of malnutrition. Similarly, hospitals within our network have also published
on their experiences. Tampa General Hospital is one such example, using the toolkit in a
multi-pronged approach creating interdisciplinary teams of staff, they identified gaps in care that
could be improved through a series of changes to their hospital-wide clinical workflow.
Following this implementation over a 7 or 8 months or so,
these QI processes led to a 25% reduction in length of stay and a 36% reduction in
infection rate. This study adds to a growing body of literature on QI
processes that can be undertaken to better identify and treat malnourished patients.
Given the intense interest in reducing health disparities and advancing health equity, I want
to share some contemporary data from our learning collaborative sites. Recent analyses demonstrate
wide variation in eCQM and outcome measures across age, race, ethnicity, and rural versus urban
geography. On this slide, you will see a snapshot from a descriptive analysis revealing disparities
in the burden of malnutrition across different racial and ethnic groups as identified by RDNs.
Additionally, the readmission rate for non-Hispanic Black individuals with
malnutrition was more than 26%, compared to less than 19% among non-Hispanic White individuals.
We were simply scratching the surface by these descriptive analysis.
I think there may be more opportunity to dig a little deeper in future research.
Malnutrition is a complex and burdensome condition that is often connected to social determinants of
health. Tracking hospital performance can lead to the detection of food insecurity.
We recently held a multi-stakeholder roundtable to discuss the connections between health equity,
hospital malnutrition care, and food insecurity. The participants' directive was to identify and
share solutions that could be readily implemented. Prior to the meeting, we interviewed national
experts to gather baseline information about factors that drive nutrition-related disparities,
existing barriers to addressing malnutrition, and potential roles for hospitals in identifying and
treating food insecurity. This really set the stage for what we could do within the
MQii to advance health equity through quality measurement. We see this as the next frontier.
On this slide, we start to weave in opportunities to identify and engage
patients around food insecurity by anchoring it to the global malnutrition composite score.
While we believe that this is an ideal approach,
we think that it can also serve as a playground for future research.
With a growing number of food pantries co-located in hospitals and the rise of home delivery of
medically tailored meals post-discharge, perhaps we can take a closer, more rigorous look into the
effectiveness of these programs. Through the MQii, we've had the opportunity to work with
several hospitals who have identified malnourished patients and have implemented small, short-term,
innovative nutrition interventions post-discharge. That said, there is a call for additional
studies that could be tackled to increase our evidence base. From generating evidence around
ROI to comparing efficacy of different nutrition interventions. There is a lot of work left to do.
I hope that this presentation has provided ample fodder for thought. I think that nutrition
field is well-positioned to tackle health equity through generating meaningful data,
building strong partnerships, and disseminating the findings so that learnings can be replicated.
Such research can be anchored in the acute care setting. Thank you
again for the opportunity to share a bit about the MQii. It is indeed a national
treasure and perhaps a good starting place to kick off some of this future research.
DR. KIRK KERR: Hi. My name's Kirk Kerr. I'm a senior manager of Global Health Economics and Outcomes
Research at Abbott Nutrition. And I'd like to talk to you today about the economics of nutrition in
health care. By way of disclosures, I'll note that I am an employee and stockholder of Abbott
and that this presentation is not intended for continuing medical education purposes or credit.
Health economics and outcomes research is all about demonstrating the value of
treatments and interventions to a variety of health care stakeholders, for example,
once a health care stakeholder is a health care administrator who has to make decisions about the
treatments, interventions, and protocols that will be used at their institution.
Health care payers and policymakers make decisions about what treatments,
interventions and interventions will be covered by their government program or their health insurance
policy, and how much they're willing to pay for those health care treatments or interventions.
Health care providers make decisions about what interventions...and treatments will
best return their patients to optimal health. And patients balance the need to improve their
health with the costs that they will bear to cover the cost of treatment—health care treatment.
Health economics and outcomes research combines our understanding of the clinical outcomes of
treatments and interventions with health economics to answer whether the outcome that we're getting
from a treatment or intervention is worth the spend on that treatment or intervention.
In the case of nutrition care, one asks; How much are we spending on nutrition or malnutrition?
And the answer is quite a lot. So, a study in 2014 found that the burden—economic burden of disease-
associated malnutrition was $157 billion a year. Much of this burden was borne by the elderly,
65 and older population. This burden was calculated to be over $50 billion per year.
A subsequent study found that the economic burden of malnutrition was felt in all 50
states and the District of Columbia. And while it varied across those states from as low as about
$40 in one state to as high as $60 per capita in the District of Columbia, it was present
and felt and was significant in each state. Again, the burden fell most heavily upon the 65
and older population, with the burden ranging from $80 per person to over $120 per person per year.
So what can be done to reduce this burden?
One intervention that has been found has been nutrition-focused quality improvement initiatives,
and these have been shown to be effective at improving patient care and have several
aspects in common or components in common, typically. The first component is to identify
those patients who are at nutrition risk using a validated nutrition screening tool.
Of those patients who are identified to be at nutrition risk, a dietician
should meet with them to conduct a individualized nutrition assessment
to understand the nutrition needs of the patient. The patient's physician should also
meet with the patient to make an appropriate diagnosis of malnutrition when appropriate.
The physician, dietician, and the patient's entire care team plan should work together to develop a
nutrition care plan to provide education to the patient on proper nutrition and how nutrition
is important to health and improving and achieving the patient's optimal health.
Implementation of these measures at an acute care hospital was shown to be able to be improved over
a 4-month period. A hospital implemented a screening, nutrition assessment diagnosis, and
development of a nutrition care plan and was able to improve in all four of these
quality improvement areas. But what about the patients? What is the impact on the patient? Well,
a quality improvement initiative at Tampa General Hospital was implemented,
and this implementation included the automation of a dietician consult request to ensure that
dietician consults with at-risk patients happened in a timely manner.
Additionally, dietician recommendations were automatically inserted into the patient's care
plan to ensure that the nutrition care plan was developed and implemented in a timely fashion.
Additionally, patients with certain diagnoses were provided immunonutrition to improve their
overall nutrition status. This quality improvement initiative was found to reduce
infection rates in patients by 35% and also reduce hospital length of stay by 25%.
And both of these improvements were achieved without an increase in readmission rates.
Another quality improvement initiative was implemented at Advocate Health Care
in Illinois. This initiative included nutrition screening for all patients,
education and training of clinical staff on appropriate nutrition care,
provision of oral nutrition supplements as part of a nutrition care plan for at-risk patients,
and patient education on proper nutrition and how to improve their nutrition status.
This quality improvement program was found to reduce hospital length of stay by 25% and hospital
readmissions by 29%. And these improvements led to a savings of $3,800 per patient.
Additional quality improvement initiatives in other settings of care have found similar
improvements. An initiative in home health care focusing on screening of patients,
education of those who are at risk, and providing oral nutrition supplements to improve
nutrition status resulted in an 18% reduction in hospitalizations and savings of $1,500 per patient.
In an outpatient setting, a similar program of malnutrition screening, patient education, and
nutrition recommendations led to an 11% reduction in overall health care
resource utilization and savings of $485 per patient.
In conclusion, I'll note that we've seen that malnutrition creates a significant economic
burden on the U.S. health care system, but that this burden can be addressed through quality
improvement initiatives that identify and treat patients at nutritional risk. We've seen that
these quality improvement initiatives can improve patient outcomes and reduce health care costs
and that these improvements are possible across a number of settings of care.
I'll direct listeners to malnutritionquality.org to find toolkits
for implementing nutrition-focused quality improvement initiatives at their own institutions,
as well as measures to improve documentation and reimbursement of nutrition care.
For future research, I would encourage researchers to look at specific populations, such as patients
with diabetes or at risk for diabetes. Look at the...one could look at the impact of
the National Diabetes Prevention Program. Look at other ways that nutrition and nutrition programs
can assist patients with diabetes. Another population of interest might be oncology to
understand how nutrition interventions can improve continuity of treatment of these
patients or improve their overall outcomes. Additionally, as value-based payments,
initiatives and programs are gaining in popularity, it's important that these be
studied to understand their impact on patient care and patient outcomes. Thank you very much.
(BACKGROUND CONVERSATION)
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.
We have a nice chunk of time allotted here, so please do go to the question and answer tab on
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by accessing this platform. So, just go ahead and do that and you can get this content all again.
So, welcome to our speakers. Thank you for joining us today. I would like to, I think, start at the
beginning and just talk about our definition of malnutrition. So, Dr. Jensen, I believe you're
here with us via telephone. We can't see you, but I understand you're here, and I am wondering
if you can just spend a couple of minutes talking about the definition of malnutrition.
You went through that as it relates to disease-related malnutrition and inflammation.
This is a really helpful construct for us in the context of malnutrition within U.S. hospitals.
But I've always found it a little bit confusing when we look at this as it's stratified with
sarcopenia. So, you shared that the definition for disease-related malnutrition includes loss
of lean tissue and functional capacity. We know that that's one of the attributes that we look
for the diagnosis. But yet, if I look at the ASPEN definition and several papers in the literature,
they seem to stratify them separately where we have malnutrition with or without sarcopenia. Yet
it seems to me that so very often and sarcopenia, by virtue of looking at muscle mass and functional
capacity, is incorporated into the definition of malnutrition. Is there really a meaningful absence
of malnutrition in individuals who are diagnosed with sarcopenia? Have studies been done to see
if we can really find major populations that are sarcopenic yet well-nourished?
DR. GORDON JENSEN: Thank you very much for the insightful question. I view sarcopenia
and also cachexia as malnutrition overlapped syndromes, and I very much think that they
are not necessarily distinct types of malnutrition. They are in, you know,
well-described settings in terms of, you know, what sarcopenia looks like, what cachexia looks
like. They both can have intimate ties to disease-related malnutrition as well. But
the malnourished state in these overlap syndromes is in fact consistent with the malnutrition that
we've been describing in hospital settings quite often. And, you know, we're making attempts to
work very closely with the cachexia and sarcopenia groups to arrive at a broader consensus. There's
days I think we're close; there's days I think we're further apart. But I think
the key take-home message for both sarcopenia, and cachexia as well, is these people are often
malnourished. And associating with those conditions, there's very good research data that show
that malnutrition is often part of sarcopenia. Of course, it quite often is of cachexia as well.
But the important take-home message for all should be to recognize that those overlapped syndromes,
these people are malnourished. It's important to recognize that, and it's important to intervene
as appropriate. So, that's a succinct answer, but thanks for a great question.
DR. KELLY TAPPENDEN: Well, thank you. We have a question from the audience asking you, Dr. Jensen, to comment on
the association of inflammation—inflammation, and presence of malnutrition and difficulties
correcting malnutrition. This person's concern is that as strong as this association might be,
we do not understand the mechanisms of this association, and it's not clear to them that
there is a direct, causative relationship, at least in any individual, and not so clear that
anti-inflammatory approaches do help in cancer cachexia, which is their field of practice.
DR. GORDON JENSEN: The first observation I would make is that in very severe inflammatory states,
it's very difficult to make a favorable impact with nutrition and certainly with
nutrition interventions alone, which I would not recommend at all because it is imperative to treat
both the underlying disease and inflammatory process as well as the malnutrition. Now,
I'm not for a moment suggesting that that means one should withhold malnutrition—withhold
nutrition intervention in these settings because it's fundamentally important in helping people
get through potential treatment interventions. Medical treatment interventions are fundamentally
important in terms of perhaps blunting further deterioration to some degree. But fundamentally,
the premise is correct that you have to address the underlying disease and inflammatory process.
And of course, there's lots of very interesting research looking at potential interventions,
you know, whether it's omega-3 fatty acids, whether it's probiotics, whether it's improved
glycemic control—a host of opportunities here. And, you know, part of it is going to be
recognizing people in these states early, tailing in our interventions to specific disease states,
specific types of inflammation. And of course, these are outstanding research
themes to be further explored. I think the key understanding here is why it's important
to understand the contributions or underlying disease on inflammatory response is it impacts
upon our assessment, it impacts upon the types of interventions that we would bring to bear,
and it also impacts upon the outcomes that we could expect and share with clinicians and share
with patients and their families. So, I think I'll wrap that up before I take up all the Q&A.
DR. KELLY TAPPENDEN: I have just one more question, though, on this topic. There's...
is there anticipated future development in assessing for
sarcopenia with CT scan evaluation? This is a question from a dietitian.
DR. GORDON JENSEN: Yeah. I think the body imaging techniques for body composition are sort of,
you know, the current state of the art if you will, and CT scan and to look at muscle mass
can certainly be used to look at sarcopenia. You know, the challenge has been and, you know,
Vickie Baracos, has done a wonderful job with this, is, you know, it's hard to get someone
to do a CT just to look at body composition. But you can take advantage of those that are
being done for clinical purposes. So, you know, it wouldn't be all that unusual for someone with
sarcopenia to also be getting an abdominal CT to look for some underlying disease or what
have you—certainly very common in cancer, for example. And with the appropriate CT imaging,
you can take advantage of that and the appropriate analysis and use CT to get, you know, muscle mass.
DR. KELLY TAPPENDEN: Thank you. I want to open this up to several of our other speakers now.
When CMS is auditing hospitals and assessing if institutions have been over-reimbursed for
malnutrition diagnosis, what are they using as assessment criteria? Dr. Guenter,
perhaps I could ask you this.
DR. PEGGI GUENTER: Yes. So, what I was going to say is there will be a full discussion later by
Marsha Schofield on inpatient reimbursement, and I think she'll cover this nicely.
Meetings that we have had in the past with CMS, there is not a universal malnutrition diagnostic
indicators and characteristics that they're using, and it's a bit difficult to understand what the
criteria they're using are. So, I think, but I think that's moved along a little bit more,
hopefully in discussions with CMS, and I think Marsha will cover that nicely.
DR. KELLY TAPPENDEN: So, Kristi, on that topic, what do you
recommend then as part of the quality initiative when it comes to coding?
DR. KRISTI MITCHELL: So, I mean...
DR. KELLY TAPPENDEN: I know it's not one of the four things, but, you know.
DR. KRISTI MITCHELL: Yeah. So, I just want to just point out that in our work with the Malnutrition Quality
Improvement Initiative, we're not focusing on coding as much as we're focused in on
the important steps around the malnutrition care process. So, as much as I would love
to answer that question about coding, I don't think I'm well positioned to do so. Thank you.
DR. KELLY TAPPENDEN: So, does anyone else want to comment on that to me? Because it strikes me that although
as we nutritionists are very motivated to do that, part of the value to the hospital
is in fact being able to code and get that value-added reimbursement, right? Dr. Kerr.
DR. KIRK KERR: Yeah. I agree the...a big part of the value of the...that's trying to be demonstrated by
initiatives like the ASPEN Value Project and the Malnutrition Quality Improvement Initiative is
to show that malnutrition is an ongoing challenge in hospitals and that properly coding for those will
allow the hospital to get reimbursed for that and to receive the value that of the work that they're
doing because they are doing...patients who are malnourished have more co-morbidities, they're
sicker, and they need more care, and the hospitals need to be reimbursed appropriately for providing
that care. And anything that can be done to make sure that those hospitals are appropriately
reimbursed, or those institutions, not just limited to hospitals, but any institution that's providing
that care for malnourished patients, they need to be reimbursed appropriately.
DR. PEGGI GUENTER: Peggi. This is Peggi Guenter again. I just want to make another comment on that.
We have shown several times over the years using HCUP data that we know that malnutrition
diagnoses are probably not being coded as often as they should. The latest study we have from
2018 is a rate of malnutrition at 8.9%. And we know from individual studies that it goes
up in an individual reviews in institutions or in small studies, that it goes up to 30,
even up to 50% in really high-risk patients. So, we know there's a disconnect between what's
being diagnosed, what's being assessed, what's being diagnosed, and then what's being coded.
And that's another step beyond even the global composite measure. But I think it will lead
to better coding if...once these measures are implemented in an inpatient reporting system.
DR. KELLY TAPPENDEN: Dr. Guenter, actually I sure hope so.
That first 2010 paper and then 2018, I cite that all the time because it just underscores the
problem that we have. I'm very grateful for the Quality Initiative and making sure that we're
going through that process, but how sure can we be until that process is completed, right?
And I think that those data are really reflective of that. Alright. Dr. Winkler.
DR. MARION WINKLER: I just wanted to add a couple of just real-life clinical scenarios. I've done a number
of appeals on behalf of or helped on behalf of the hospital and our clinical documentation people
when a malnutrition diagnosis was questioned or not reimbursed. And some of the discrepancy
historically has been the reliance on serum albumin level as triggering it. And with the
shift in the AND and ASPEN the criteria and implementation of that over the last really decade
now as we begin to do our documentation according to that or the appeal according to that and the
process we use, there's a discrepancy there. Now, it seems to be shifting. There are a number of,
I guess, auditing companies that help hospitals prepare for this. So,
I'm seeing much more triggers based on the AND and ASPEN criteria. So, that's a good thing.
What is also happening, though, is that there's benchmarking against institutions with larger,
similar-sized institutions. And one of the things that's really been
bothering me, I guess is a good term, and I hope we'll have some discussion during
this whole conference is when we look at the number or percentage of malnutrition documented
or coded for and our levels are lower, that there's actually a push to increase that.
And so I want to have some conversation at some point on how do you use the benchmarking. Because
my interpretation is if we know we are documenting it and treating for it, then it's better to have
a lower percent of malnutrition in our patient population that that's actually a good thing.
DR. KELLY TAPPENDEN: Okay. Very good. We're going to talk about
this issue more in the session after our break. So, right now there's a question
for Dr. Kerr on the how the financial savings were calculated in your presentation.
DR. KIRK KERR: Sure, so the financial savings are calculated by comparison of patients who were
seen in the hospital after the Quality Improvement Initiative was initiated and what their health
care costs were and comparing those to patients who were seen before the Improvement Initiative
was initiated. And so, it's an average of the health care costs of those two different groups,
an average of the difference of the health care costs between those two groups of patients.
DR. KELLY TAPPENDEN: And then in follow-up to that, Dr. Kerr, how can therapy, such as
OT or speech, be best utilized to increase outcomes in the field and patients with
respect to nutrition and malnutrition, specifically in the outpatient and home
health settings? How can we collaborate with these other allied health professionals?
DR. KIRK KERR: I think those are great questions. I think that there needs to be that collaboration
and an integration of care with those groups to ensure that the patients are receiving the best
care possible. The studies in particular that we looked at that I mentioned looked at patients
who were receiving a standard of care plus something related to nutrition...a nutrition
screening and the nutrition recommendation. So, I can't speak specifically to how those
were integrated other than they were part of the existing standard of care. What
patients received was whatever was part of the existing standard of care in those institutions.
DR. KELLY TAPPENDEN: It's a really good point, Dr. Guenter, I don't know if you're familiar with any literature,
but is there good evidence looking at involving a variety of specialties
in malnutrition care? Do we have evidence to show that that helps?
As presumably it wouldn't in many situations, right, but are we utilizing our colleagues enough?
DR. PEGGI GUENTER: I think we probably are not. But I don't know that...there certainly doesn't seem to
be any cost data and value data that I know of. But I think it's certainly something that...as we
move along with a standardized tool to do these steps and we start really beginning to correctly
look at quality measures and get a baseline of what we actually have in terms of malnutrition,
I think that the biggest problem is, you know, we don't know what we're looking at. And Marion,
I think, probably sees all the patients in her hospital and knows...is very comfortable that
her rate is lower. But when I look at 8.9% on a national basis,
somehow I think that we've missed people because then we look at studies that have 30 or 50%. So,
I think we've got to get together with all of these efforts we're doing with
validation of its tool, with putting in quality measures, I think we'll get to our baseline
and we'll know what we're dealing with, and then we can begin to look at care models that would
include things like OTPT and speech therapy. We can look at specific interventions. We need
to study really homogeneous populations. We can't say all hospitalized patients, we can't say all
cancer patients. We have to look specifically when we're doing intervention studies and randomized
prospective studies that were looking at a specific population because nutrition, you know,
needs and nutrition outcomes are going to be very different for each of these populations.
DR. KELLY TAPPENDEN: Yeah, we've got so much work to do. So, from Rebecca and Tomason, is GLIM and/or
ASPEN preferred for insurance reimbursement? We have had a few rejections from Blue Cross
Blue Shield who won't take GLIM. Does anyone have any insight into that?
DR. PEGGI GUENTER: This is Peggi Guenter I really think it would be best to wait until we hear from Marsha,
who's really a wonderful resource, Marsha Schofield from the Academy. She's got a lot
of good sense of this. I think Gordon may...also Dr. Jensen may also have some insight
on this as well. But I think just trying to wait a little bit on this discussion would be great.
DR. KELLY TAPPENDEN: Yeah, let's do that. So, is anyone familiar with malnutrition
identified in cancer survivors? If so, what are possible screening tools, causes, treatment
interventions? Can treatment of malnutrition and inflammation with diet or probiotics
decrease cardiovascular disease risk and outcome? So, we've got a broad
range of questions there regarding cancer and CVD-specific identification of malnutrition.
I think this really does underscore the need we heard several times for us to have handles
on specific populations and diagnoses. And, you know, we've got such broad data across a
number of patients, but we need to understand specific diagnoses and stratify patients more.
We have another—
DR. GORDON JENSEN: I have—
DR. KELLY TAPPENDEN: Please.
DR. GORDON JENSEN: I can go ahead and make a quick comment on that if you'd like. It's Gordon.
I think it is imperative as you just said, as Peggi just said, that when we start talking about
testing interventions for populations or diseases, it needs to be very specific, well-characterized
subgroups. And, of course, if you talk about it in the context of research priorities,
I had highlighted in my presentation that among the first that really warrant that kind of,
you know, the significant randomized controlled trials will be those where we think there are most
likely fundamental opportunities for success, where we have a high likelihood of validating
the successful outcomes associated with our intervention. So, I would just emphasize,
as you said, that I think that that is imperative as we think about future research priorities.
DR. KELLY TAPPENDEN: Thank you. We have a question from Carol Jennings from AdventHealth, who
is very interested in the clinical sequelae of malnutrition in the near term, for example.
What is the timeframe where we would see clinical manifestations of muscle loss and vitamin deficits
within a week or two? Our references all reflect longer-term timelines, and when speaking with the
physicians, it's hard not to sell...to convince them that malnutrition impacts their very thin
patients, but for those that are overweight or normal weight, they are slower to recommend,
accept the recommendations for nutrition. What strategies would any of you recommend to Carol?
DR. GORDON JENSEN: Well, this is Gordon again. That's a very good question and that data in my clinical
life I encountered virtually weekly. And in terms of what the timeline of malnutrition—in this case
undernutrition—is very much dependent on the severity...the setting, and the severity of the
insult, so, you know, acute critical illness, for example, you know, intensive care, trauma, burns,
all sorts of things. Those people can become profoundly undernourished very quickly—days,
week, or two. And of course, acutely you will see, you know, micronutrient changes, protein changes .
To demonstrate erosion of muscle mass can be very difficult in those kinds of settings. But again,
some of the imaging techniques that we're beginning to use could be quite helpful.
If that's just pure semi-starvation, the timeline certainly can be somewhat longer—weeks to months.
And of course, it's not until you're in the time, in the realm of 30% weight loss that
you're talking life-threatening malnutrition. So, the timeline can vary considerably.
I think the importance is to demonstrate to clinicians that are asking, you know, why do
you want to intervene upon my patient, that we can, you know, literally at the molecular level—
whether it's metabolic profile, whether it's micronutrients, whether it's proteins—we could
demonstrate fundamental changes in nutritional status and impact upon outcomes in an adverse way
relatively early in a clinical course. And of course, I appreciate that we you have a very large
patient in a hospital bed, it's not obvious they're losing muscle, it's not obvious that
they have micronutrient deficiencies. And of course, one of the priorities for the workshop
is to talk about better ways we may be able to identify and demonstrate malnourished patients
based on laboratory screening, based on metabolic profiling, based on risk. So,
a lot of work to do, but it's very important. This, I think, is alluded to here to dialogue
with clinicians about what we know, what we don't know. I mean, I think a very important,
you know, very important thing is to also be upfront, which is we know
we don't believe that albumin and in pre-albumin are very useful malnutrition indicators in the setting of
disease and inflammation, for example. But I'll stop there. Thanks.
DR. KELLY TAPPENDEN: Great answer. Thank you. I'm going to shift our focus for the last question of this
session, and that is from one of our audience members: How can we control malnutrition in
developing countries, specifically where there's no good concept of nutritionists and dietitians,
and doctors mostly prescribe their patients with dietary guidelines? So, this makes me
think of GLIM versus the AND/ASPEN criteria for malnutrition. Who would like to address that?
International countries where there are not nutritionists and dieticians represented,
and doctors are sort of left with just standard guidelines for their patients.
DR. GORDON JENSEN: Well, if no one wants, I'll be happy to quickly take that on, because,
of course, this is one of the fundamental, you know, rationales that underpin GLIM,
the Global Leadership Initiative on Malnutrition, where it was specifically designed to be used in
settings where there weren't necessarily an abundance of clinical nutrition resources,
skilled dieticians, certainly not body imaging for body composition, as well as other resources. And,
you know, the vision with GLIM was they could be used much more widely. But I do want to be clear
and people don't realize this, there's plenty of places in North America where these resources are
also not readily available in terms of recognition of malnutrition and intervention and follow up.
But on a global setting, the intent with GLIM is very much to have a simple, user-friendly
approach that can be used in a great diversity of settings across the globe. And of course,
you know, it's undergoing validation testing now. There's still a lot of work to do,
you know. In terms of North America, you know, the vision there is that, in fact, if GLIM is
used as the initial approach with screening and assessment, it generates a preliminary diagnosis
of malnutrition that then should be confirmed by more comprehensive assessment by a skilled
dietitian or other practitioner. But...thank you.
DR. MARION WINKLER: It probably also speaks to the gap of the need to train practitioners
across all disciplines, and that could be global as well.
DR. KELLY TAPPENDEN: Absolutely. Alright, with that, I want to thank each of our presenters for
your excellent presentations and thoughtful insight into this. We will now take a quick
break for the second part of our first session, which will begin at 2:15 PM Eastern. Thank you.
DR. KELLY TAPPENDEN: Welcome back. I'm pleased we'll be able to continue with session one now with
presentations on Improving Assessment to Nutrition Care. I'm your moderator
for today. My name is Kelly Tappenden from the University of Illinois at Chicago. Now,
what we have planned is that Dr. Hand will begin the session with a presentation on the
Optimal Number of Registered Dietitians Needed to Address Malnutrition-Related Issues. Then Marsha
Schofield will discuss Inpatient Payment Issues. That will follow with Dr. Nepple presenting on
Malnutrition Diagnosis During Adult Inpatient Hospitalizations. And our last presentation
in the session will be by Dr. Grega on Lifestyle Medicine Reimbursement. Again, during the session,
please do share your questions for the presenters in the chat box and
then afterwards we'll get together and discuss it all. Thanks very much.
DR. ROSA HAND: Hello, and thank you so much to the organizers for inviting me to give this brief talk on the topic
of Optimal Number of Registered Dietitians Needed to Address Nutrition-Related Issues.
During these 10 minutes, I hope to describe the current knowledge of registered dietitian
staffing in inpatient settings, describe research in progress related to staffing and malnutrition,
and finally, to describe future research needs related to RDN staffing. So, I'm going to
start by reviewing three existing studies on the topic of RDN staffing in the inpatient setting.
The first study was published in 2015. In this study, we used a large sample from across the
country to describe the time requirements for inpatient encounters based on facility,
patient, and RDN characteristics, and then developed a model that would
predict registered dietitian staffing needs that would be similar to other facilities.
In this project, we had both adult and pediatric facilities participate, but I'm going to focus
on the adult data for this presentation. As you can see from the characteristics,
we had 78 adult facilities participate and they contributed just over
35,000 patient nutrition encounters. We had a nice spread of facility size and facility acuity.
One of the first things that we were able to identify in this 2015 study was that the time
needed for nutrition encounters increases as the registered dietitian-assessed patient complexity
increased, which is logical and which was statistically significant by ANOVA. It is
important to note that this slide has combined adult and pediatric time and complexity data.
After the initial description of the encounters, we conducted a three-level regression model to
account for clustering of the data and random variation among registered dietitians and
facilities. And we were able to come up with the predictive model that you see on the screen that
allows a clinical nutrition manager to determine the number of minutes of direct nutrition care
time that they would need in their facility based on patient characteristics, including whether or
not the patient is in the ICU, the number of patients who are high or moderate complexity,
and the number of patients who need an initial assessment versus a reassessment.
Very soon after we published that study, Wendy Phillips published a study using data
from 420 different hospitals that used Morrison Healthcare to manage their registered dietitians.
This study defined and reported things a little bit differently than our study,
but they identified that the average time per encounter was 25 minutes.
This was not separated out by complexity. And so, I think that when you consider an average
complexity, this is fairly similar to our other 2015 study. So, to summarize, both 2015 studies
used self-reported data and did not collect outcome, so, they could not establish an ideal
amount of nutrition care time; they could just benchmark the amount that's currently provided.
There was very little movement forward on the question of registered dietitian staffing since
these two papers came out. However, in preparing for this presentation, I was able to find an
interesting case report that was published last summer regarding how nutrition staffing
was accomplished for the field hospital that was set up during the COVID-19 surge in New York City.
You can see that this group established a number of registered dietitians needed
for clinical encounters based on the number of beds that were occupied. So, for example,
at 250 occupied beds, one full-time equivalent was needed. And at 375 beds,
two clinical dietitians plus a critical care dietitian were needed. But clearly, the gap that
remains from all of these studies is the linkage between dietitian time and patient outcomes.
However, this is quite a complicated linkage and something that we've been thinking about
for quite a long time. So, I'd like to just briefly review some of the considerations that
make this linkage complicated. First of all, poor nutrition status is closely related to
other medical conditions. And so, the time that's required for nutrition care and the effectiveness
of nutrition interventions provided by registered dietitians might be mediated by those underlying
medical conditions. Nutrition interventions are complex, and they might change over time,
meaning multiple nutrition encounters that should be captured in the time data.
And finally, from a research perspective, both of the 2015 studies use the registered
dietitians as the subjects and did not collect any personal medical information. And so,
we did not have to obtain consent and HIPAA authorization from the patients. But of course,
once you start collecting outcomes, which are essential to this question, you do have to collect
informed consent and HIPAA authorization. So, that complicates the research protocol a little bit.
So, the Academy of Nutrition and Dietetics has been working on a study to both validate
the Academy/ASPEN diagnostic indicators for malnutrition and also to look at staffing needs
that might be related to malnutrition. The full study protocol has been published, and Dr. Alison Steiber
will be talking a little bit more about the validation portion later in today's session.
So, I want to focus in on the staffing part of that study and introduce just a
little bit of preliminary data so that you can understand who participated
in this project and where we're going. So, there were 38 dietitians who provided
care and have so far provided adult data to this study. And you can see from this side that we
have a nice spread of experience and the expected distribution of dietitians with a graduate degree.
Similarly, for the 37 adult hospitals from which we have data at the moment,
we have a nice spread in terms of characteristics, including a case mix index that's very similar to
what we saw in 2015 and a nice spread in terms of the urbanicity of the participating facilities.
So, this is just some data about the nutrition care for adult patients in this study. The
dietitian-assessed complexity was low for 16% of the patients, moderate for 55% of the patients,
and high for 30% of that the patients. So, there's fewer high-complexity patients than we had in
the 2015 study when we were at almost 40% high complexity, but I think that's because of the
intermingling of pediatric data in the complexity data that I showed earlier in this presentation.
When you look at the time required for the patient encounters in this data,
the average time is about 43 minutes. And in our 2015 study, it was 31 minutes
for high-complexity patients. So, I would attribute this difference and the longer
length of time in the more recent study because this is all initial encounters, and in 2015
we included both initial and follow-up encounters.
Also in this slide, you can see the proportion of patients that were in the ICU, 19%, and the total
number of nutrition-support contacts that patients received during their 90-day follow-up period.
You can also see that about 10% of the patients had malnutrition as their nutrition diagnosis.
So, clearly, there's a lot more to be done with this data from the new study in terms of looking
at what patient characteristics predict or modulate, the amount of time required,
and then looking into the outcomes data to determine the linkage between time spent
with the patients and staffing level, so connecting staffing level to outcomes.
I think some other remaining research gaps include staffing for other conditions. So,
in patient settings, what other non-malnutrition conditions might modulate staffing requirements?
We should also examine dietitian staffing for other specialty areas and settings. For example,
we know that there's a lot of work to be done with prevention and treatment of malnutrition
in follow-up settings, and so, what do staffing needs look like in those settings?
And then something that's a major interest to our clinical nutrition managers and that we
have very little data on is how to appropriately staff for nutrition care needs on the weekend.
And the last thing that I'd like to suggest as an important research gap in this area is
really thinking about the quadruple aim. So, we know that the quadruple aim thinks about worker
wellness and preventing burnout and maintaining a high-quality healthcare workforce as a way to
also improve the quality of patient care. So, when we think about the drivers of burnout, you can see
in the box I've highlighted three, including excessive workload, inefficient processes,
and the electronic medical record. And so, all of these things are closely aligned with staffing.
And as we potentially modulate the number of patients the dietitians are asked to care for,
we really need to monitor for risk factors and signs of burnout.
So, thank you, and I look forward to answering questions during the live Q&A.
DR. MARSHA SCHOFIELD: Thank you for the opportunity to speak to payment issues related to the
identification and treatment of malnutrition in the hospital inpatient setting. While I'm
going to address payment issues, I can't stress enough what, as clinicians, we already know. The
primary reason we address malnutrition in hospital patients is because we want to provide quality care.
At the same time, there are potential revenue streams we can tap into to support the delivery of
such care, hence why I'm here today to talk about payment issues. But first and foremost, we're
identifying and treating malnutrition because it's the right thing to do for our patients.
To understand the payment issues around inpatient care for malnourished patients, you first need
to understand payment for inpatient care in the United States. Let's start by looking at who pays
for inpatient hospitalizations. Based on data from 2020, the largest proportion of hospital
inpatient stays are paid for by private insurance, followed by Medicare at 30%, and then Medicaid.
But when we look at who pays for stays related to malnutrition, this data from 2016 shows
Medicare as the expected primary payer for almost two-thirds of inpatient stays related
to protein-calorie malnutrition. This point is important as we look at how payment for inpatient
care is determined. While Medicare payments for inpatient stays are complex. The simple
explanation is that Medicare bases payments on diagnosis-related groups or DRGs based on the
primary reason for the hospitalization, which is actually determined after discharge. Cases
are classified into Medicare Severity Diagnosis Related Groups or MS-DRGs based on the principal
diagnosis and up to 24 additional diagnoses. And they're paid at a rate based on the average
resources used to treat patients in that DRG. In addition, certain diagnoses are designated
as a major complication/comorbidity, or MCC, or a complication/comorbidity, CC,
and may result in a higher Medicare payment to account for the more intense levels
of care and/or longer lengths of stay. As you can see, several diagnosis codes
for malnutrition are deemed an MCC or CC and may qualify for increased reimbursement for Medicare.
But for that to happen, not only must the medical diagnosis be determined by
the physician, but also a plan of care must be implemented during the hospitalization.
And it takes only one CC or MCC to shift the MS-DRG and hence reimbursement. Most state
Medicaid programs and private insurances also pay based on DRGs, although actual rate may vary from
those used by Medicare. It's also important to note that while a nutrition care plan developed
and implemented by a dietitian is a cornerstone of inpatient care for persons with malnutrition,
there generally is no separate payment for inpatient nutrition consultations and services.
As clinicians have done a better job of driving quality in patient care by identifying
malnutrition, the increase in malnutrition diagnoses and associated payments has caught
the attention of CMS, as well as private payers. In January 2018, the Office of the Inspector
General included in its work plan a new project to assess the accuracy of Medicare payments
for the treatment of severe malnutrition. They issued their report in July 2020 and
with their findings that 173 of 200 claims reviewed did not correctly bill Medicare for
severe malnutrition diagnosis codes, resulting in an estimated overpayment of $1 billion.
Then in November 2021, the OIG announced its plan to move on to study Medicaid inpatient hospital
claims. The report of that audit is anticipated sometime next year. What have been the issues
identified by the auditors? Unfortunately, despite efforts by the Academy of Nutrition and Dietetics,
ASPEN, the American Society of Nutrition, and the Association of Clinical Documentation and
Integrity Specialists to find out the specific criteria being used by the various auditors,
there's a significant lack of transparency. But we learned through a survey we conducted
in 2018 of members who had been the subject of audits, whether government or private,
and through other anecdotal reports, as well as conversations with payers, that denials of hospital
inpatient claims for severe malnutrition are related to one or more of these factors.
First, auditors are using criteria or definitions of malnutrition that don't
align with current knowledge. And they're looking for a nutrition care plan that doesn't align with
currently accepted clinical practice guidelines. Specifically, they want to see evidence of a low
serum albumen. They want to see that the patient has a low BMI. They also want to
see that patients with severe malnutrition are treated with enteral or parenteral nutrition.
Well, our associations collectively have been trying to work with government auditors on
their procedures, these issues point to several important research opportunities.
We need to validate diagnostic criteria for malnutrition in adults and children.
So, a huge thank you to everyone who's currently involved in those validation studies.
We also need further research on the optimal interventions and outcomes,
both clinical and cost, for treating the various types of malnutrition. For example,
are enteral or parenteral nutrition really necessary in all cases of severe malnutrition?
Which malnourished patient populations benefit from specific types of interventions?
And how do we best pay for the identification and treatment of malnutrition across the entire care
continuum? As I said at the beginning, our primary impetus for identifying and treating malnutrition
in the hospital setting should be quality care. At the same time, we can't ignore the fact that
healthcare is moving in the direction of linking payment with quality and value.
As we saw, Medicare and other payers recognize the additional resources needed to treat inpatients
with malnutrition. And many hospitals are leveraging the increased payments to fund
more RDN positions. But there's a new opportunity to impact inpatient revenue streams and support
research endeavors around malnutrition care. And that's through the global malnutrition
composite score, the first nutrition quality measure, which CMS just adopted as part of the
hospital inpatient quality reporting system. This quality measure pulls together data on
the four essential steps in malnutrition care - screening, nutrition assessment,
documentation of a diagnosis of malnutrition, and developing and implementing a nutrition care plan.
Beginning January of 2024, hospitals can elect to report on the global malnutrition composite
score as one of their three voluntary electronic clinical quality measures. If the hospital meets
CMS criteria for reporting under the hospital inpatient quality reporting system, they can avoid
a .2 for 5% reduction in their payments. Use of this composite measure will not only support
quality malnutrition care, but it provides a financial incentive for doing so. Plus, it offers a
valuable tool to support research on both clinical and financial outcomes of malnutrition care.
Thank you again for the opportunity to share these insights with you as
we all work together to address the gaps in our knowledge related to malnutrition
in clinical settings with the ultimate goal of improving health outcomes and quality of life.
DR. KEN NEPPLE: Good afternoon. My name is Ken Nepple, and I'm a urologist who specializes in
cancer treatment. I appreciate the invitation to talk about malnutrition diagnosis during
adult inpatient hospitalizations. Ten minutes will go very quickly. So, I'm going to focus
on two topics. First, I'm going to discuss different definitions of malnutrition in adults. And second,
we're going to focus on the variation in the prevalence of malnutrition as malnutrition is noted much more
commonly when using nutritional screening or dietitian evaluation versus less commonly when
using physician hospital diagnosis data. In addition, we'll take a look at some efforts
we have made to improve documentation to bridge that gap. Along the way, I'll try to
identify potential opportunities in malnutrition research. Missing malnutrition in hospitalized
patients is not a new concept. This seminal paper by Charles Butterworth was published 43 years ago.
However, contemporary literature continues to show that malnutrition is underdiagnosed.
This summary information for the Malnutrition Quality Improvement Initiative notes the often
cited figure that 20 to 50% of hospitalized patients have malnutrition versus only
8% rate of malnutrition diagnosis based on administrative data looking at hospital diagnoses.
Why does this gap exist? One aspect to acknowledge is that prevalence will vary based on definition.
It makes common sense that before you measure something, you need to define
it. In the context of this NIH workshop, it's notable that if you go to write a grant that
terms are clearly defined, with one term having one definition. However, in the nutrition literature
and in clinical practice, the one term "malnutrition" can have many definitions.
Let's look at a few definitions over time. The WHO document in 1999 was focused almost entirely
on severely malnourished children. However, one figure had a BMI cutoff of less than 16,
as required for a diagnosis of severe malnutrition in adults. Obviously, that
definition lacks clinical validity, as patients with obesity can still develop malnutrition.
Over time, there have been multiple nutritional scores that were developed, and while each had
value, the lack of a consensus definition was a significant barrier. In response, a 2012 consensus
statement was developed based on having at least two of six clinical characteristics, including
inadequate energy intake, weight loss, fat loss, muscle loss, edema, or reduced grip strength.
Surveys have shown this is the predominant current method for malnutrition assessment.
More recently, the GLIM criteria was published in 2019.
That criteria was developed from a ranking of different characteristics. This group advocated
for keeping the criteria of weight loss, muscle loss, and decreased intake, with the
addition of an option of a BMI threshold and an acknowledgment of disease burden and inflammation.
The GLIM criteria require an etiologic criteria as above. Then a phenotypic criteria is used to grade
the severity based on meeting one of these three different characteristics. Regarding the multiple
definitions of malnutrition, opportunities exist for comparative effectiveness research evaluating
which criteria are best associated with outcomes. Also, it should be noted that more stringent
criteria may potentially increase the risk of missing malnutrition in some patients.
My earliest clinical memories of malnutrition assessment as a surgical resident were checking
albumen and pre-albumen levels. Notably absent from the consensus statement and
the consensus report are these laboratory assessments, with the stated exception that
CRP can be used as a supportive lab to evaluate for inflammation.
As a clinician who practices in cancer and oftentimes uses biomarkers,
it can be stated that an unmet need is to develop an accurate biomarker in malnutrition.
Let's transition into looking at the prevalence of malnutrition during adult hospitalizations.
In 2008, Norman and colleagues did a review of 20 different prospective and retrospective studies,
which were aimed at determining the rate of malnutrition in hospitalized
patients and reported a range varying from 20 to 50%. However, in contrast,
a study assessing malnutrition diagnosis from discharge data of more than 39 million patients
between 1993 and 2010 found that the reported rate of malnutrition diagnosis was only 3.2%.
However, that report had noted that the rate was increasing some over time.
After that prior 2010 report, our group wondered, "Did the 2012
consensus statement impact the diagnosis of malnutrition during hospitalizations?" Also,
could it be that academic medical centers did a better job of diagnosing malnutrition? Our
group added to the literature by evaluating a database of academic medical centers. That
database was called UHC, but it's now called Vizient. We were able to look back and see how
many patients had malnutrition diagnosed during hospital stays in 2014 and 2015.
However, our findings noted that malnutrition diagnosis continued to be infrequent, as only
5% of adult inpatients had a malnutrition diagnosis in 2014 and 2015. Subsequently, our group sought
to improve the malnutrition assessment process by using technology-enabled workflow to bridge that
gap between dietitian assessment and physician diagnosis. In 2014, I invited myself onto a
malnutrition pilot project at our hospital. To my benefit, I was the only physician that
showed up to the initial meeting. I got the opportunity to work with our hospital group,
where we evaluated the patient process from pre-admission to admission nursing screening,
then nutrition dietitian consult, then to provider diagnosis and treatment.
By understanding the process and where data did and did not exist, we were able
to identify gaps and opportunities for improved workflow. We took the 2012 consensus statement
and operationalized it within the electronic health record. The details are beyond the scope
of this presentation, but in short summary, we created workflows that added discrete data to the
dietitian assessment and made that information readily available to providers to use in their
clinical practice and their documentation and progress notes and discharge summaries.
Remarkably, the pilot showed that with this workflow,
physicians could document more consistently which of their patients had evidence of
malnutrition, as the malnutrition diagnosis rate increased to 42%.
The pilot workflow was subsequently implemented housewide and contributed to institutional
support for nutritional care, including more dietitians and ultimately development of an
advanced nutritional support inpatient consult service that is staffed by a gastroenterologist.
Over time, this process has continued to evolve and has shown sustained growth in
the accurate identification of malnutrition.
In closing, with the last couple of minutes, as a cancer surgeon, I want to specifically advocate
for malnutrition research in cancer patients. The momentum is starting to build for nutritional
optimization in cancer patients, who are at high risk of malnutrition due to the catabolic
nature of cancer. Here are a few examples of work advocating for nutritional research
and cancer patients, and a summary paragraph that I had drafted in a prior grant proposal.
As one example, bladder cancer patients who have
muscle invasive disease require major surgery with radical cystectomy and urinary diversion.
Enhanced recovery protocols are now widely utilized in this cystectomy population.
And specifically, there's an ongoing SWOG randomized trial to look at the potential
benefit of immunonutrition compared to placebo in cystectomy patients. Further research is needed
to evaluate which nutritional interventions have the most impact in surgical patients.
Here is a schematic that we developed on taking a multidisciplinary approach to
malnutrition assessment in surgical populations.
I borrowed this slide from Dr. Sarah Psutka, who's a urologic oncologist at the University
of Washington, with her permission. Notably, they used radiographic assessments with CTs to evaluate
for sarcopenia. Even when controlling for standard TNM staging and other clinical characteristics,
they found that sarcopenia was associated with worse survival after radical cystectomy,
even when controlling on multivariate analysis. This really brings up the potential
opportunity for radiomics to establish a radiographic biomarker for malnutrition.
Lastly, 35 randomized controlled trials had been published on the use of arginine supplementation
in surgical patients. However, these results have not been widely disseminated. For example,
when I first learned about this, I discussed with our colorectal surgeon at my institution,
and they were not even aware of these protocols even though they had been developed in the
colorectal population. This is an opportunity for further dissemination and implementation research.
Thanks again for the invitation, and I'm very much looking forward to the workshop.
DR. MEAGAN GREGA: Hi, everyone. I'm Meagan Grega, a family medicine doc who is also board certified
in lifestyle medicine, and the Co-founder and Chief Medical Officer of Kellyn Foundation. Thank
you for inviting me to talk about the amazing potential of lifestyle medicine approaches
for patients with malnutrition, along with the challenges in implementing those programs due
to reimbursement issues. Some of my favorite words of wisdom on how to approach a challenge come from
Albert Einstein. He said, "We cannot solve our problems with the same thinking we used when we
created them." As we grapple with the epidemic of chronic disease and years of quality life lost in
our country, the search for innovative solutions must include lifestyle medicine approaches,
especially those focused on optimal nutrition. And unfortunately, despite our high-tech medical
care and pharmaceutical interventions, we are not succeeding in our quest to improve health,
vitality, and longevity. We've had several years of decreasing life expectancy in
the U.S. even before the COVID-19 pandemic. The decreases in life expectancy were largely
related to increases in all-cause mortality in young and middle-aged adults, with a significant
contribution from organ system diseases like hypertension, diabetes, cardiovascular disease,
and obesity. What this data shows us is that while our pills and procedures are helpful
in slowing the trajectory of chronic disease, they are not able to fully combat the effect of
lifestyle choices that increase our risk of death and disability. For a country that spends over
$11,500 per person every year on health care, we are not getting a good return on our investment.
And when we look at the risk factors that are causing a decrease in healthy life expectancy,
we find several that are often related to the food choices we consume,
such as high BMI, poor diet, alcohol use, high fasting blood sugar, and hypertension.
Now, the good news is we can do better. A research paper published in February utilizing data from
the 2019 Global Burden of Disease study evaluated the impact on life expectancy when switching from
a standard Western diet to an optimal diet. This diet is not a vegan or even a vegetarian
diet, but it is a plant predominant, minimally processed diet. Transitioning to an optimal diet
from a Western diet at age 20 resulted in over 10 years of increased life expectancy,
with even greater increases seen for men. Just as exciting, transitioning at age 60 or even
80 results in significant years of life gained. This study highlights the importance of food as
medicine initiatives that support and encourage patients to transition to healthier choices.
But unfortunately, this study published in March highlights how much work we still have to do to
shift the social norms of our country towards healthy eating habits. NHANES data evaluated
diet quality scores for adults 65 and older and found that the proportion of adults with
poor diet quality increased from 51% to 61%. Those with intermediate diet quality decreased from 49%
to 39%. And those with ideal diet quality remained consistently low at 0.4%. So, regarding healthy
lifestyles, there's no lack of information. There is lack of implementation. And
implementation is the goal of the American College of Lifestyle Medicine. Lifestyle medicine is the
evidence-based practice of helping individuals and communities with comprehensive lifestyle
changes to help prevent, treat, and even reverse the progression of chronic diseases by addressing
the underlying causes. So, a major barrier to successful implementation of lifestyle medicine
approaches, including those focused on supporting patients in their transition to optimal nutrition,
is the current reimbursement landscape. There are many obstacles to providing comprehensive
lifestyle medicine services, but I would like to highlight four main areas today—fee-for-service
models that do not adequately support the delivery or the reimbursement of Lifestyle Medicine care;
inadequate payment level for billing codes associated with lifestyle change;
insufficient accessibility of Intensive Therapeutic Lifestyle Change Programs for
patients due to inadequate reimbursement or administrative challenges with licensing and
reporting requirements, and lack of reimbursement for "Food as Medicine"
strategies, such as "Healthy Food" Prescription Vouchers and Medically Tailored Meals.
Let's dive into the first two areas in more detail.
A recent clinician survey by ACLM revealed that 55% of respondents reported
not being able to achieve reimbursement for their Lifestyle Medicine services.
The current RVU system pays for volume of care, not for performance or outcomes. So,
this focus on quantity over quality penalizes providers engaged in the
long-term relationship building and frequent support necessary for effective behavior change.
Additionally, there are misaligned incentives and quality measures that reward medication
prescribing, such as statins, and penalize deprescribing when lifestyle changes have
improved biometrics. Practitioners can have financial consequences when they successfully help
patients improve their lifestyle choices and then deprescribe medications that are no longer needed.
The very nature of lifestyle medicine requires longer and more frequent visits to support
behavior change, which is often best delivered in a group setting, such as a shared medical
appointment. But in these scenarios, patient co-pays for frequent visits are often a deterrent.
Additionally, the place of service NPI number limits access for patients
in community settings, such as schools, places of worship, and teaching kitchens,
which may be more convenient and accessible gathering places, rather than holding all sessions
in a health care facility. There's often limited or no reimbursement for interdisciplinary care
team members, and one of the most urgent matters to address is that the Medicare coverage for
medical nutrition therapy is currently only for patients with diabetes and chronic kidney disease,
when so many other patients with chronic nutritionally related diseases could benefit.
Another issue is the inadequate payment level for billing codes associated with lifestyle
change. Many of us are familiar with the common 99213 office visit code that typically covers a
15-to 20-minute visit with a patient. A typical level of reimbursement for a 99213 is $92.47.
Contrast that with spending the same 15 minutes with a patient but counseling on
lifestyle choices to address obesity and assisting the patient with education and goal setting.
If you use the G0447 code for intensive behavioral therapy for obesity, your reimbursement drops to
$26.31. If you choose to provide the educational content and goal setting in a shared medical
appointment, which is a very effective and efficient way to engage several patients with
the same condition and provide support as part of the therapeutic modality, a 30-minute visit
is reimbursed at only $12.97 per patient. A similar scenario plays out with the diabetes
self-management codes, both individual and group. These payment rates do not add up to sustainable
reimbursement for the vital and necessary role of lifestyle counseling for optimal behavior
choices that we know creates the foundation for prevention and treatment of chronic disease.
So, what are some of the research opportunities to improve this situation?
First, let's quantify the improvement in clinical outcomes and just as importantly, the return on
investment for intensive therapeutic lifestyle change programs. Programs like the Diabetes
Prevention Program and Intensive Cardiac Rehab have demonstrated impressive clinical outcomes.
But despite these clinical outcomes, accessibility of ITLC programs are often
limited by reimbursement issues and licensure requirements. For example, the maximum Medicare
DPP payment is $705 for an entire year-long program if all metrics of weight loss and
attendance are achieved, which is less than the reimbursement achieved with eight 99213 visits,
something most physicians can complete over a 2-hour time frame in the clinic.
Next, let's evaluate the effectiveness of healthy food prescription vouchers for patients with
chronic diseases related to malnutrition. The Health Incentive Pilot program for SNAP
beneficiaries was a great start in this direction. It provided a 30% incentive for every dollar spent
on targeted fruits and vegetables for 12 months in a randomized population of SNAP beneficiaries. It
found significant improvements in fruit and vegetable consumption, and cost-effective
analysis predicted a net cost savings of $824 per capita. If we are willing to pay for blood
pressure meds and diabetes drugs, why aren't we willing to pay for broccoli and legumes?
The only side effects will be good ones, and the health care savings will accrue every year.
There are so many great research opportunities to talk about, but I would like to end with assessing
the impact of medically tailored meals. Studies of medically tailored meals have been small,
secondary to resource constraints, but those that have been done are associated with fewer
inpatient and skilled nursing facility admissions and approximately 16% net health care cost savings
and a 50% increase in medication adherence. In closing, there's compelling evidence that focusing
on optimizing nutrition will improve patient longevity and vitality while decreasing health
care costs. So, here are some calls to action. Contact your elected representatives and urge
them to pass the MNT Act. This legislation will significantly increase the number of
chronic disease diagnoses: that are eligible for medical nutrition therapy reimbursement.
Remove the place of service NPI requirements for community locations, making group visits where
people live, work, and play more accessible and sustainable from a funding standpoint.
Create payment models that allow for longer and more frequent appointments,
and also advocate for reimbursement for the interdisciplinary team members.
Change the co-payment requirements for patients engaged in Intensive Therapeutic
Lifestyle Change programs or frequent shared medical appointments for chronic disease
management to remove that financial barrier for patient participation. Reform quality measures
that incentivize medication prescribing, such as statins and diabetes medications,
as opposed to patient outcome metrics. And lastly, provide reimbursement models for Medically
Tailored Meals and Healthy Food prescription vouchers. Thank you so much for allowing me
to speak with you about both the potential and the pitfalls of lifestyle medicine reimbursement,
and I look forward to an invigorating conversation during the panel discussion.
DR. KELLY TAPPENDEN: Thank you so much for that. Thank you, I want to thank each of you for your
great presentations. To our audience, please do share the questions you have in the chat
box, and I will try and make sure that we get to all of them as we go through. So, Dr. Grega,
thank you very much for that great presentation. I was impressed with the list, the calls of action
that you had to the end there. How do we as individuals impact that legislation, though?
DR. MEAGAN GREGA: That is an excellent question. But as we are all voters, and we all have
representatives that we can talk to, I think it's the most important thing is getting the
information out there about how ridiculous it is that we pay so much money on the current state of
how we take care of patients. And of course, we still need to be able to do all the things like,
you know, it's interesting my presentation was mostly about outpatient versus inpatient,
which was what a lot of the other presenters were talking about. Now,
we definitely still need all that inpatient and medication and procedure accessibility. But as
we know from our disease statistics, if you are going to have an acute illness or a car accident
or something like that, the United States is a fabulous place to get your health care. If you
have a chronic disease, then it's not doing so well for your longevity and your outcome. So,
I think just showing that if you are going to see a patient and spend 15 minutes talking to
them about medication, that your physician is going to get paid four times more than if they're
going to counsel you about what you're eating. And your lifestyle is something that most of
our elected representatives would not realize. And they would not realize how low the Diabetes
Prevention Program reimbursement is when we know that people who have diabetes spend thousands of
dollars more every year on health care costs. So, if we could prevent that or if we could prevent
that trends, the transition from pre-diabetes to diabetes, we could save a lot of money. So,
mostly, I think it's advocacy, awareness, and explaining to people the differences
between how different services are reimbursed because I think that's a real black box for
most people. We have no idea when we go to the doctor or when we go to the dietician or
go to any of our health care facilities, what the costs are and what the reimbursement is.
DR. KELLY TAPPENDEN: Is there a coordinated letter-writing campaign that's
available to help us as we contact our representatives and senators?
DR. MEAGAN GREGA: You know, that's an excellent question. I believe the American College of
Lifestyle Medicine is doing that for the Medical Nutrition Therapy Act. But other than that,
it is more of a one-on-one going and talking to your representatives. But I would recommend
people get in touch with the American College of Lifestyle Medicine because they do have
staff members that are working on advocacy in Washington and on a state-by-state level.
DR. KELLY TAPPENDEN: Alright, thank you. I want to start by asking Dr. Hand, how do you recommend that
clinical nutrition managers take into account or action the data that she shared with us? And do we
know beyond the hospitals that you looked at our current staffing levels for registered dieticians?
DR. ROSA HAND: Yeah, thanks, Kelly. So, I think we've heard from some clinical managers that they have
been able to use the equations that we present based on the 2015 data to successfully compare
their current staffing to the current or at least eight years ago staffing figures other
similar facilities. And in some cases, they've been able to use that data to demonstrate that
they need more staff. I think at this point, we have not done enough analysis of the new
data from the academy ASPEN malnutrition criteria and validation study to be able to say anything
about advocating for higher staffing levels. However, I just say keep posted we certainly
plan to make some recommendations about staffing levels that might improve patient outcomes, and
so, look for that in the literature in the coming year maybe is an optimistic
expectation, but we certainly are bringing in that data and working currently on analyzing it.
DR. KELLY TAPPENDEN: OK, very good. Thank you. And Marcia Schofield,
what advice can you provide to payers who are...providers, pardon me,
who are very afraid of payers denials regarding the diagnosis of malnutrition?
DR. MARCIA SCHOFIELD: Thank you, Kelly. Yeah, I understand anxiety audit is real. And out there,
especially after the OIG report, the best advice that I can give, and this is actually advice from
a consortium of organizations that have been working on this issue, Academy of Nutrition
and Dietetics, ASPEN, American Society of Nutrition, and the Clinical Documentation
and Integrity Specialists, is some of it comes down to good documentation. You know, that you
when a physician makes a diagnosis of malnutrition, that the medical record
supports that diagnosis. And also, as I mentioned during my presentation,
that there's a plan of care in place. It should not add the complication or comorbidity to the
hospital billing for malnutrition in any form if there isn't a plan of care associated with it. So,
evidence-based practice combined with solid documentation to support what you're doing
and the plan of care to go along with it, I think those are key.
DR. KELLY TAPPENDEN: And we had one of our audience members ask about whether or not there was a preference
for the GLIM or the Academy ASPEN criteria for recognition of malnutrition. What they
said was that Blue Cross Blue Shield prefers GLIM in their experience, but can you comment on that?
DR. MARCIA SCHOFIELD: Sure. It's so inconsistent out there and it's not always clear. As professional
associations who look at the evidence, we don't recommend one set of criteria over another. They
both need to be validated as previous speakers today have already noted. And I'm sure more will
speak to that fact as well. So, I understand from a payer standpoint that it can drive your practice
along the way and you want to be cognizant of what they're looking for. But it still comes
down to evidence-based care. And in the absence of validation of either set of criteria, I think you
just need... I don't have any reason to recommend one over the other at this point in time.
I can imagine it could be pretty crazy with all the payers out there to try to tailor your
systems based on what each payer is looking at. So, I just suggest doing consistent care pathways
based on the best available evidence and document. Many people have successfully dealt with audits
and claims denials with just good documentation and the science to back it where it's available.
DR. KELLY TAPPENDEN: Very good. We have another member who has asked about the usefulness of the
global malnutrition composite score. Can any of you comment on that?
DR. KENNETH NEPPLE: Yeah, this is Ken. I could comment on that. Our institution was kind of the validation site
for the Electronic Clinical Quality Measures. And so I think it's still yet to be seen
how that will be used in different practices across different places. But I know one of
the lessons that we learned was the more you can try to automate that process ,where the
dietitian starting from the nursing screening is clearly seen by the dieticians' group to be able
to say who's seen sooner or later. And then a really important part was when the dieticians
do their documentation is that clinically evident to the provider group, and specifically what those
electronic measures are gonna be based around is being able to have workflow within the electronic
health record where you can pull out that data. And so we're kind of in the process of
expanding on some of the work we did previously to operationalize that. But I think what it does open
up is a lot of conversations with our quality and safety group about what they're currently
reporting and comparing the pros and cons of changing to...including that new composite measure.
And I would just add one comment on the prior question.
Because I also at the institutional level respond to denials partly because it upset
me to see people from the insurance side not accurately evaluate this patients. And so
I think it's really apparent that there's a very broad spectrum of reasons for denial. Some of
those are valid, some of those are completely invalid. What we did institutionally was to
base our documentation primarily off the consensus statement from the Academy and ASPEN. But then when
we started to see more denials related to GLIM, we also supplement with documentation that says
this patient also meets GLIM criteria. I think the insurance companies have noticed that GLIM
is more stringent and that's potentially to their benefit. And so in the lack of
clinical validation, I think they look at financial validation as choosing a definition.
DR. KELLY TAPPENDEN: Thank you. We also have a question from an OT who works with patients with
diabetes and cancer and is also a Ph.D. student focused on lifestyle medicine. So, they want
to ask Dr. Grega and Nepple two questions. How can a person like themselves do more to increase
health outcomes for their patients receiving OT, PT, or speech with regard to providing nutrition
education when they don't have a diagnostic code on malnutrition? And then secondly,
as a Ph.D. student, how do you recommend they get more involved with research in this area?
DR. MEAGAN GREGA: I'll jump in first and then see what Dr. Nepple has to add to that. And I would say,
well, a couple things. It depends on, like where you are, what's your work situation. So,
do you have colleagues that you can refer the person to? Is there somebody else who should be
kind of evaluating whether this person has issues with malnutrition? And a lot of what we see is
really kind of like, overcaloric but undernutrient nutrition in a lot of our
patients. And is there a way that you can kind of bring this person to the attention of that other
colleague in your system who may be able to do the actual diagnosis code and the billing? But if not,
one of the things that I love to talk about with my lifestyle medicine family docs and internal
medicine docs, and say, like, how can we do this as part of our regular care is I
love to give patients homework. So, if you're working with them, and as a PT or as an OT,
and you're doing your type of service, but you can also have some time to talk to them about like,
"Hey, have you ever read the book Blue Zones?" You know, "Have you ever thought about watching,
you know, this documentary?" One of the ones that I love to recommend is called PlantWise.
It's for free from AdventHealth. It's something that you can Google it and you can have patients
watch it for free. And say, "Hey, just see what you think. Look at it, maybe talk to your provider
about it." The other thing, if you become a member of the American College of Lifestyle Medicine,
which maybe you already are, we have a ton of handouts and I know that the dietetic
associations do as well that you can give to patients. You just have to be thinking about
like what other care providers in this patient's care should be involved with the education that
you're providing. And as far as research with the American College of Lifestyle Medicine,
we have a lifestyle medicine economic research consortium that is trying to
support and also get people more involved in research and lifestyle medicine. So,
that would be a place that I would look. But also if you're part of an academic health
center or if you've got a college or university in your area, that's another place where I see
a lot of lifestyle medicine, nutrition type medicine, fit our food as medicine
projects that are being launched. Dr. Nepple, what do you think?
DR. KENNETH NEPPLE: That's a really good answer. I think one thing that kind of popped up to my head,
it's hard to tell physicians that they don't know much about something. And for a lot of physicians,
you know, I think it's a challenge because we're not really familiar with the criteria for
malnutrition or in the definition, but I think specifically as an occupational therapist I've
learned from our dietitians kind of the focused exam, what do you see as far as areas of different
muscle wasting? And as an OT or a PT, you're going to have some insight into muscle weakness.
And I think as you spend time with the patient, a straightforward question is to ask if they've
lost a lot of weight. And so I think relatively quickly you could develop yourself into sort of
an expert where beyond just doing the usual stuff if you're noticing that a
patient has significant muscle wasting and they have weakness and they've lost weight,
we may be so busy as a clinical service managing medications and getting X-rays
and doing surgeries that it may not be on our radar that this patient has something
that could benefit from nutritional consultation. And I think as a provider if you end up becoming
familiar with some of these teams, you know, not telling someone they need to get a nutrition
consult, but say, "Hey, I saw this patient. I noticed they're a lot weaker than I would expect,
they have this muscle loss, they've lost this weight. I was just wondering if these
things are on your radar and if it might be beneficial for them to meet with a dietitian." So,
I think that sort of approach is helpful and you can really become an expert because you're
already face to face with the patient maybe more than any of the physicians actually end up being.
And I think similarly, on the research standpoint, it's just reaching out and finding groups that
are looking at different questions. And I think there's always a benefit of having
different insight when you're trying to do interdisciplinary or multidisciplinary research.
DR. KELLY TAPPENDEN: OK. I want to carry on those slots by asking you, Marcia a question from Melissa
(INAUDIBLE) at Ohio State Medical Center, and that is if a malnutrition diagnosis is not provided,
no plan of care is proposed, is that something other disciplines OT, PT, speech can recommend
so that their patients can get the best care, or will this be a problem in auditing?
DR. MARCIA SCHOFIELD: Yeah. Thank you, Kelly. And I think I'll build on the two previous
responses as well. Certainly a couple points I want to make. Team-based care is very important.
And I think in the end of the day, having the team of professionals working with the physicians and
everybody else and the patient to come up with a plan of care assessment, all of that thing,
everybody can play a role. There's also a difference that I think sometimes gets lost
between doing screening versus assessment. I think any members of the healthcare team can
look at screening for risk of malnutrition. So, many of the things that Dr. Nepple had mentioned,
you know, anybody can do that screening. The assessment piece, though, where you actually
get into what is somebody's nutritional status. Are they actually malnourished,
of what type? And what's the appropriate treatment and intervention? There, you start getting into
scope of practice and legal aspects of what somebody can legally do within a specific state
based on licensure requirements, for instance, or once again just your education and credentialing.
So, physicians can certainly do nutrition assessment and come up with plans of care.
Registered dietician nutritionists, that's within their scope of practice to do those things. Yes,
OT and PT have components of the consensus statement things they can do like handgrip
strength type of thing, just that functional capacity. But I would say if you're talking
about actually making a diagnosis of malnutrition and coming up with an appropriate care plan,
I think you definitely have to be careful because you could be violating licensure
laws for both physicians and registered dietitian nutritionists if others move
beyond nutrition screening into the assessment side of things.
DR. KELLY TAPPENDEN: So, is it OK for the RD or RDN to pull that information from the
OT/PT assessment like handgrip strength, gait speed, sit-stand?
DR. MARCIA SCHOFIELD: Absolutely, absolutely. You know, different people are doing different
things. Dr. Nepple talked about the nutrition focus physical exam, which the dietitians are
trained to do. That's where in this world where we want to be careful that we're not providing
duplicate care, right, that becomes costly for the system. And even for patients going
through why do I have to have the same tests done multiple times, we certainly can draw on
the expertise of everybody on the team and the assessments that they've done. And I
think that helps the physician ultimately make the diagnosis.
DR. KELLY TAPPENDEN: OK, very good. So, when we think about things like the global malnutrition composite score, are we
to the point where we have these scores validated to predict response to a nutrition intervention?
We have lots of data showing that nutrition interventions matter, right? And when I think
in critical care, there's some data showing that certain patients with a high malnutrition
score will respond to intervention. But what about in other disease states?
DR. KENNETH NEPPLE: Based on the silence,
I guess I'll take that one. The way I think about that composite score, it's really an institutional
assessment. And I think to some extent, it shows how much is malnutrition assessment on the radar
at the institutional level. When we looked at the prevalence of malnutrition diagnoses,
one of the things we did in that study, because we had access to star ratings of different hospitals,
we looked and said, were higher quality, you know, supposedly higher quality hospitals
with more stars, did they do a better job of assessing malnutrition? And we found a
statistically significant relationship there. I think there's some caution that that's not
necessarily a cause and effect, but that's an association where these types of things that may
not be as recognized by all institutions, if your institution is doing a good job of recognizing,
then it may mean that they're doing a lot of good things in lots of other spaces too and
it may even mean that you have resources to be able to look into these different spaces.
I think from an outcome measure, the randomized controlled trials of immunonutrition
clearly show that at the patient level, if you're identifying in managing,
supplementing that there's benefit, I think there is some question in those
types of studies, do you even need to screen if everybody needs the same type of treatment?
But I think there's definitely a gap in looking at patient-level outcomes.
But for me, institutional support leads to paradigms that even though there may not be direct
evidence, it makes sense. For example, in our cancer center, we used to not have a dietician.
And so I remember hearing someone getting sent to the local grocery store as an option because
there was no dietitian available. As we built up support, now there's a dedicated dietitian. So,
there's someone who's available for those consultations. And if you're discharging someone,
you can plan to have them see a dietitian as in follow-up. And you can see how it's not a far
jump from no nutritional counseling to appropriate counseling by a specialist has got to be better and at
least is a better patient experience. I think ideally we would have data on
decreasing readmissions and those types of things. But it's just a little bit more,
you know, it's very difficult to evaluate that when you're not sort of in a situation where you
can randomize versus if you had drug one versus drug two, that's a much easier situation to study.
DR. KELLY TAPPENDEN: Right. So, my understanding is that as part of a QI initiative, the score at this point,
the Global Malnutrition Composite Score, really looks at whether or not steps have been done,
right? It's a process as opposed to being able to have measured outcomes at this point. So, another
important area of research, I think we have a lot of things where we're recommending processes,
but we need to have now those data substantiating with outcomes. Another question then from our
audience is, if one of you could talk about the importance of albumin...the albumin globulin ratio
for determining malnutrition over albumin alone, and is that ratio checked in healthy outpatients?
DR. MEAGAN GREGA: I think I would defer that to some of the dietitians in our group here. Dr. Hand.
DR. ROSA HAND: So, I'm not totally familiar with this. I think, Kelly, if you wanted to take a stab,
that would be great. But I think I can fairly confidently say that this is not
commonly checked in healthy outpatients. I can't speak to the value in hospitalized patients.
DR. KELLY TAPPENDEN: I would have to agree I'm not familiar with it being commonly used.
Are there any inpatient comments on this?
DR. KENNETH NEPPLE: On the physician side of things, you know, checking albumin in
laboratory analysis was part of what we had done previously. But I remember the first
big meeting we had with our dieticians and when we reviewed that consensus statement,
that, you know, thought is that laboratory measures are not as accurate. So, we're not,
even in the consensus statement or GLIM, laboratory assessments are not part of that. So,
we have not been using laboratory assessments. However, I think that's an area if someone in
the future were to validate that, there may be benefit. But it's not part of our practice here.
DR. KELLY TAPPENDEN: OK, very good. One final question then before we break. And it's just sort of a nuts
and bolts question, Dr. Nepple, for you. And that is what are the steps that you went through with
your technology-enabled workflow? You know, who do people talk to to get such efficiencies built
into their systems at their hospital? What's your recommendations there of the how-to?
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
think it's a couple of things. It's just getting everybody in a room, including the informatics
folks. And I think the one thing I've really kind of learned over time, because I work a lot with
our informatics group, too, is they want to know that somebody else has already done something and
that you're not inventing something that is not going to bring value or is really hard to
operationalize. And so now I think there's enough examples out there of how to do this workflow
that it's really just a matter of getting the right people together. And we've provided a few
resources in the past about how to operationalize within EPIC or other electronic health records.
But it's...for us the big push was also having the quality and safety people at that group in
the hospital finance group too. Because we could have developed a really good workflow,
but we really didn't know how beneficial it was as far as driving other things within the hospital,
improving quality metrics because of risk adjustment, or improving hospital reimbursement.
So, having those people in the room once the pilot was successful,
very quickly, hospital leadership was asking, you know, how do we make this the workflow for all
places? And moving into the pediatric population and other things like that. So, I think it's
really starting with the right people in the room and then telling people that this is not a super
hard heavy game that's going to require years and years of work. It is really just figuring out
what are some discrete things that you can do to improve communication via people understanding
what other groups are doing, and then documenting that as discrete data within the record.
DR. KELLY TAPPENDEN: Very good. Now, Dr. Hand, is there anything from the RD
workflow perspective that you would specifically add to that?
DR. ROSA HAND: That's a great question, Kelly. I think that the data that we have on dietitian
staffing to this point is nowhere near that granular. So, we have information about
how frequently patients are receiving assessments versus reassessments,
or are they receiving just one encounter or multiple during the hospital stay? And we
have information about how frequently they're receiving interventions, including nutrition
education. But in terms of the workflow, I think very often that's too individualized
by hospital for us to easily collect data on it. So, that is potentially another area of research
opportunity is, you know, a standardized way of setting up this workflow for dietitians.
DR. KELLY TAPPENDEN: OK, very good. Now, in reference to my very first question to Dr. Grega
about the excellent call to action with specific things that we can do,
I'm told that the Academy website has an action alert that any of us can go and receive specific
guidance regarding that. And that's not just providers of different disciplines,
but patients also. So, with that, I want to thank each of you for your excellent presentations,
the audience for their engagement and questions. And now we'll take a quick
break before joining Dr. Seres for Session 2, which will begin at 3:40pm Eastern. Thank you.
DR. DAVID SERES: Welcome to session two entitled "Moving Beyond the Terminology of Malnutrition."
I'm Dr. David Seres, and it's my honor to be your moderator for this session. I'm Professor
of Medicine in the Institute of Human Nutrition, Director of Medical Nutrition, and associate
Clinical Ethicist at Columbia University Irving Medical Center in New York City. Just as an aside,
you'll note that our oral introductions to our illustrious speakers is brief, their CVs are long,
but this is to maximize the time for the presentation. So I call your attention to
the presenters' button, the button for which is in the controls on the left side of your screen.
Brief titles for the speakers appear if you open that window up, but there's a link to a more
complete bio for each. Also, the controls for the media player which will show you the live videos
of the presenters during the Q&A session is in that same section. This session, which is titled
'Malnutrition in Clinical Disease: Moving Towards Developing a Unified Definition of Malnutrition'.
In it, we'll be addressing what I think is the fundamental question currently
surrounding our approach to malnutrition and the credibility of what we do every day, and that is,
what is it that we're really describing when we call things malnutrition? For this afternoon,
we have several speakers and then we have a couple...we have several more tomorrow.
Charlene Compher will be speaking about the current methods for diagnosing malnutrition.
I'll be giving a talk about how nutrition... malnutrition as it's currently defined
is actually a marker for disease severity. Phil Schuetz from Switzerland is going to be talking
about the results of some of his work in the effort trial, which Dr. Jensen alluded to, and
talking about inflammation and how its interplays with the diagnosis. Patrick Stover is going to be
talking to us about the consequences and treatment of micronutrient deficiencies. Katherine Tucker
will be talking about nutritionally vulnerable and hidden hunger, tying on to some of what Nancy,
from the Partnership for a Healthier America, talked to us about earlier today.
And then we'll go to a Q&A session,
and then tomorrow we'll be talking about things like body composition and different
disease-specific cachexia states. So, on that note, let's get started.
DR. CHARLENE COMPHER: Hello, I'm delighted to be with you today to talk about updating what we know about
malnutrition in adults in clinical settings, and to project what we need to know in the future.
What is the Global Leadership Initiative on Malnutrition? This is the, an approach to
diagnosing malnutrition that resulted from an ongoing collaboration among recognized global
leaders in the field of nutrition support. One goal was to enable busy clinicians with
limited nutrition knowledge to make at least a preliminary diagnosis and possibly refer
to experts for appropriate intervention. A second goal was to provide a framework under
which existing approaches could be placed. And finally, we needed to develop standardized
language so that we can identify best practices in response to treatment of malnutrition.
We realized in our initial discussions in 2017 that all of the existing screening and diagnostic
tools for malnutrition used the same variables as you can see on this slide. So we set up the
GLIM approach, which is...depends on screening for malnutrition using a validated screening tool,
and then considering phenotypic criteria that are common in all of the nutrition assessment programs
and etiologic criteria of either reduced food intake or disease burden/inflammatory condition.
If they have one phenotypic and one etiologic, then they meet the criteria. But then we need
to grade the severity of malnutrition. The two approaches that are most common in the U.S. today
are GLIM and AAIM, the Academy of Nutrition and Dietetics and Aspen Indicators for Malnutrition.
As you can see from this slide, the weight loss criteria and the reduced muscle mass criteria are
very, very similar in the two approaches. However, AAIM does not include a BMI category. And the
reason is that we know that malnutrition can exist regardless of BMI level. It's entirely possible
that the BMI categories in GLIM will disappear with further research. We looked at the construct
and concurrent criterion validity when GLIM was compared with SGA, which is viewed as a semi-gold
standard in our prospective observational cohorts. If you look in the black...first black box,
you will see the percentage of malnutrition with GLIM goes from about 30% to about 80%, depending
on the clinical context. And we want to see this. We want to see that we don't get the same
prevalence of malnutrition in every group that we examined. And the box on the right,
shows you the strong sensitivity and specificity of the approach. Very similar data were
also found when the the AAIM approach was compared to SGA. We also wanted to look at predictive
validity. And these are based on... When patients are identified with malnutrition. In published
reports, the left figure shows hospital mortality was increased 1.3-to-2.5 fold, depending on,
once again on the clinical context. And the right figure shows 30-day readmissions are increased.
Well, if we diagnose malnutrition, now, what can we do? If the patient has normal GI functions,
some version of increasing nutrient intake using food or oral nutrition supplements
or tube feeds could be considered. If they do not have adequate GI function to support their needs,
then parenteral nutrition is an option, either in the hospital or at home. Does this
work? What do we know about applying medical nutrition therapy in malnourished patients?
These two randomized controlled trials in relatively small samples of European patients
demonstrated improved hospital length of stay, readmissions, and reduced complications when oral
nutrition supplement, snacks, or diet modification were applied. This is a larger study that you'll
hear more about later, I suspect, by Dr. Schuetz, but it shows the impact of...in a sample of 2,000
Swiss medical patients who were randomized to receive intense efforts to meet their energy
and protein goals or standard hospital diet. The A panel shows you the composite outcome,
which includes mortality, but other variables and the B panel is outcome. Both are significantly
improved when the...with the intervention. And what about when patients are not in the hospital? What
about when they're home? These are older adults treated with moderate or severe malnutrition, at
discharge were given two cans of oral nutritional supplement or placebo daily, 90-day mortality was
significantly reduced. Well, we know what we know, but we don't know what we don't know.
If we are able to standardize a core set of variables for GLIM, can we count on NIH
to fund this area of research? Will clinicians embrace their use? Will journal editors permit
adequate whitespace to display these data points as a strategy to permit comparisons? We've made
great progress in the past 15 years at having BMI be reported in publications,
but BMI is not the most sensitive variable to identify malnutrition in clinical settings.
Will clinical trialists report more granular data so that we can understand the impact?
Are we actually waiting too late to identify malnutrition? We know that
there is great risk of loss of lean mass early during hospital admission.
How important are weight loss and muscle mass during a hospital admission? We
use them to identify malnutrition when they have occurred prior to admission. But is it
also meaningful to note the weight loss during a hospital admission? Would the...now
we're faced with short admissions and we're faced with patients with fluid overload,
but would the availability of portable, affordable,
reliable body composition devices bridge this gap? What is a nutrition-sensitive outcome?
The...most of the outcomes I've shown you to date are objective, and they're commonly reported,
but they're also driven very strongly by the inflammatory process itself. We need to establish
nutrition-sensitive outcomes that are less impacted by inflammation. Would discharge to home
rather than a rehab center or nursing home without readmission, would that be meaningful? From a
patient's perspective, would measures of fatigue or physical function be much more important?
Can we identify a blood or urine biomarker panel? In clinical practice, we commonly review panels
of biomarkers to aid in the diagnosis and management of diseases and conditions. We
really need this for malnutrition. Can we honestly expect a homeostatic nutrition intervention to
improve the clinical outcomes from unphysiologic, extremely inflammatory challenge? Do we need to
study specific groups according to severity of illness or inflammation to answer this question?
Finally, if providing MNT does not improve outcomes in the context of severe inflammation,
does it cause harm? We know that excessive energy and protein intake
in some individuals can worsen outcomes. But if harm is not part of the picture,
is it still important to feed them, to give them a survival advantage for other intensive
interventions to improve their mortality rate? What is the longer term risk of not feeding them?
While I've updated our findings to date on malnutrition in clinical settings and the most
impactful treatment approaches that have been described to date, I recognize that I leave you
with more questions than answers. As always, a serious consideration of research opens up more
questions and answers. Dealing with malnutrition in clinical settings is no exception. However,
the fact that this workshop is focused on identifying research gaps and opportunities
is the first step towards answering these questions. Thank you for your attention.
DR. DAVID SERES: Hi, I'm Dr. David Seres. On behalf of my colleagues and myself,
on the organizing committee, we're really pleased that you're attending. Thank you. Malnutrition
is a confusing term, and we're hoping that we can create a little bit of clarity with this session.
Just to disclose, I don't have any commercial biases, but I am very opinionated and hopefully
stick to the evidence. I have a real concern about using observational research. Here's
the good example taught to me by my mentor, Ronald Koretz. I, every time I get on a plane,
go to the pilot and ask that they please not turn on the seatbelt sign because there's a
100% concordance between turning on the seatbelt sign and the ride getting rough. So, of course,
that means that the seatbelt sign must be causal. And of course, that's silly.
But a lot of our practice and science is based on that kind of thinking. In fact,
a study done at Tufts looked at the concordance between the conclusions of observational research
and the outcomes of randomized trials in nutrition studies and found that there was no concordance.
A lot of our definitions of malnutrition and malnutrition risk have been well validated,
but the problem is how they've been validated. If you look just at some recent examples,
and these are representative of going back all the way through history, that these are all basically
validating against each other and against outcomes. For instance, the GLIM and PGA predicted
outcomes, toxicity, treatment interruptions, use of nutrition support, and a decrease in quality
of life. But they did not predict whether or not the patient responded to the intervention. This is
a new malnutrition score, the Graz score, and basically, it evaluated itself against another
scoring system. And here the SGA is validated as being valuable because it correlates well with
anthropometric and biochemical parameters. But these are all sort of foregone conclusions because
so many of these include the phenomena that occur as a result of systemic inflammatory disease.
The NUTRIC score was proposed as being highly predictive of response to nutrition,
and the problem with that is the way that this was done. The paper, which actually promotes itself
as identifying patients who will benefit most from nutrition therapy, was based on post-hoc
analysis of a randomized trial, which glutamine and antioxidant supplements were given, and feeding was
given to all patients. And of course, the NUTRIC score predicted mortality very well,
as have all of these scores. In this same study, if you look, the gray area is patient, it's with a
low NUTRIC score, and the brown, high NUTRIC score that the ones with a high NUTRIC score, and the
lowest percentage of calories provided had a very strong increase in mortality. But again, these are
observational data and are not prospective in predicting response to nourishment. They only
suggest that sicker people are harder to feed.
And again [inaudible] predicts mortality. The predictive value of the diagnosis of malnutrition has been studied
at our institution. Of note, the diagnosis of severe malnutrition significantly increased
length of stay and mortality, both length of stay in the hospital and the ICU length of stay.
Of note is that the effect was much stronger in the cardiothoracic ICU. We propose that this is
due to the fact that this is a healthier population on the, as they come in and
if they develop "malnutrition", they have been in the hospital for a long time due to
more complications, whereas a lot of the other ICUs, the admissions are sicker to begin with.
We've also looked at whether or not malnutrition is predictive in patients with congestive
heart failure, and in fact, it's very strongly predictive of length of stay adding of medium six
days and increasing mortality. It also decreases the probability that the patient who's discharged
from the hospital and goes home as opposed to a facility for rehabilitation or long term care. So,
in summary, we've shown that these scoring systems that we have for malnutrition and nutrition risk
are extremely good at predicting outcomes and are without a doubt, good markers for disease
severity. However, overall they have failed to predict who is going to respond to nourishment.
And I would propose that the terms malnutrition and malnourished are absolutely not synonymous.
Otherwise, these would predict who would respond to nourishment and malnourishment
should mean that there is some sort of new nourishment that could improve outcomes.
Research questions that remain are enormous. The basic question of what, how much, by what
route and when should we feed patients is really unanswered in our sick patients. We need to find
out if any of our scores do predict the response to nutrition interventions. And in fact, there
are data that suggest that they don't. It's really no surprise because so many of them rely a lot on
the presence of inflammation and inflammation, Dr. Schuetz, in the next lecture will discuss,
actually is a negative predictor for a response to nutrition. So, we have to look at what the
parameters are that actually identify patients who will respond. We also don't know how warm
nourishment must be inadequate to be significant clinically, and we don't know what is adequate or
ideal nourishment for our sick patients. There are a number of roadblocks to this
kind of research. We don't record well how much patients are eating prior
to admission. It is inadequate or not done. It's inaccurate or not done.
SPEAKER: We are really bad at delivering enteral nutrition, especially in our ICUs. There are some
studies that would suggest that patients get 40% or less of the prescribed calories during their
ICU stays. This is due to interruptions due to procedures and perceived GI intolerance. There's
a great fear of using parenteral nutrition for calorie adequacy, and there are studies that
would suggest, at least in the very short term, that it has no benefit. And I'm partly to blame
for that fear, because we always thought that parenteral nutrition was causal in in
worse outcomes. There's new data that suggests that it's not the parenteral nutrition itself,
but rather the patient's underlying condition that is more determinant in short term ICU
studies. Randomized controlled ICU studies do not show a difference between parenteral
and enteral nutrition outcomes in patients who are randomized to get one or the other.
And then there are worries about the IRBs and research ethics, starving, "starved people."
So malnourished patients or...I should say patients with malnutrition have always
been excluded. And then there are issues of funding, because this is not an expensive drug.
So ideally, we would have studies where we deliver 100% of the entire prescribed feed. And
I've listed some of the possible things that have had impact that that have been shown. The first
step randomized trial would be to feed versus not feed and/or feeding various amounts and analyze
for the predictive characteristics and then apply those in a second randomized trial. I (INAUDIBLE)
this thing and I look forward to discussing this at our discussion session coming up.
DR. PHILIPP SCHUETZ: Hello, everyone. My name is Philipp Schuetz, and I am a Professor of
Internal Medicine and Nutritional Medicine at the Kantonsspital Aarau in Switzerland.
And today, I'd like to talk to you about the question "Does a malnutrition diagnosis predict
who will benefit from nutritional support?" Often, when we see patients at risk for malnutrition,
we discuss whether this patient actually have...has malnutrition or not, but I think the much more
interesting and important question is whether the patient will benefit from nutritional treatment.
So why do we more talk about whether the patients have malnutrition and have less information about
treatment response? And I think historically, when we look at the different malnutrition
screening tools, we have to understand that most of these tools were actually developed
based on their prognostic potential to identify a high-risk patient. So we looked at parameters that
would predict mortality or complications, but we did not have a good database based on randomized
trials to understand which of these different parameters actually separates patients who will
benefit from support and not from support. We have recently completed a very large
nutritional trial, The EFFORT Trial. And EFFORT here stands for effect of nutritional
treatment on frailty and functional outcomes in medical inpatients. And so this trial basically
studied the question whether nutritional support in the inpatient setting helps
medical inpatients and improves their clinical outcomes beyond that of nutritional outcomes.
So this was a randomized trial. You see, we did a screening of patients. We had a few exclusion
criteria, including critical care or surgical patients, patients with long-term nutrition,
or terminal patients. And all included patients gave written informed consent. All of them had a
nutritional risk screening score of three points or more, so they all had an increased risk. And
they were randomized to an interventional group and a control group. So the control group received
nutritional treatment based on the hospital usual care, so just by the hospital kitchen,
but without defining individualized goals. In the intervention group, however, we had a
dietician team who met with all the patients and developed a nutritional plan to provide optimal
nutritional care to the patients. And so here, you see this chart showing you how that intervention
was done in the trial. So the first step was risk screening. So here, we used the NRS 2002. For all
included patients, we then defined individual nutritional targets, including energy targets,
protein targets, micronutrient targets, and other specific disease-specific targets.
And after the definition of these different goals, we also came up with an individualized
nutritional intervention plan to reach these goals, starting with oral nutrition, often,
also with the use of oral nutritional supplements. But if a patient could not reach the goals,
at least 75% of the goals within 5 days, we then also have an escalation protocol
through enteral or parenteral nutrition, with the overall goal to reach the nutritional targets.
So, these are the principal findings of this trial. In the upper part, you see the risk of severe
complications, and in the lower part you see mortality. And you see the blue group
is the control group and the red group is the intervention group. And so it's clear
from the trial that the risk to have a severe complication was significantly reduced by the
provision of nutritional treatment. You see here a number needed to treat of 25 tells us that for
every 25 patients we treat, we can we can reduce one severe complication. And also for mortality,
we had a significant result with a number needed to treat of 37. So for about 40 patients
that received nutrition treatment, you could prevent one death within 30 days. So nutrition,
based on the trial results here, is a very effective treatment to improve clinical outcomes.
And also, when you take this trial, look at this trial within a meta analysis of all trials looking
at the medical inpatient population, you see there is now about 6,000 patients in such trials,
and you see there is an overall effect regarding mortality reduction of about 25%.
So patients at nutritional risk who receive nutritional treatment have about a 25% reduction
in their risk of mortality. So the trials have looked at a very broad patient population. And
of course, the question is well, do all these patients included [inaudible] benefit, or should be
more personalized nutrition? Do we have patients that may not (INAUDIBLE)? And so traditionally,
you would just treat an overall population and maybe you have some patients that have benefits.
So these are the orange patients here in this cartoon. You have maybe some patients with
no benefit and even some patients that have harm from the interventions, the blue ones.
And what we want to do is go to a stratified medicine where we understand which groups are the
ones that show most benefit. And, optimally, like in in oncology, we would go to precision medicine
in nutritional care to really understand, based on the clinical presentation (maybe the blood
biomarkers, maybe genetic information), which of the patients which patient needs nutrition and
maybe also what type of nutrition the patient needs for his or her specific condition.
So we did now. Based on the EFFORT Trial data, we did now a couple of sub analyses to better
understand if we can find predictors for treatment response. And so one of the big question was
whether the malnutrition screening assessment would be predictive of treatment response.
And you see we calculated based on the patient's data. We calculated five well-known
screening tools. And first, we looked at the prognostic value of these tools. And you see
all of these screening tools show prognostic value. So the higher the risk in the screening,
the higher the risk that a patient will die within 1 year. So this is 12 months follow up.
However, we also did a second analysis and looked at treatment response. And so here, we did not
find a very clear picture. So it's not that if a patient has a higher risk of malnutrition in
these screening tools, that he would also show more benefit from nutritional intervention.
The same was true when we looked at the GLIM criteria. And, you know, GLIM criteria seem to
be much more specific compared to the screening tools towards the diagnosis of malnutrition.
But again, GLIM criteria were also developed based on prognostic observational data,
but not based on interventional data. So from GLIM, we do not know whether GLIM patients
will have better treatment response. And so, when we looked at GLIM within our patients,
again, we found that GLIM has a very strong prognostic value, and GLIM positive patients
have a much higher risk of dying. Here, you even see 5-year outcome data, so long-term data.
But again, when we looked at treatment response - and this is here at the upper part - you see
that there was some trend that the GLIM positive patients may have a stronger response. So here
the odds ratio was 0.6, and the GLIM negative ones had, still, an odds ratio of 0.85. So also, GLIM
negative patients had a treatment response. So we looked also at other markers such as albumin,
which is considered in some hospitals still to be a nutritional marker. And we found a very similar
picture. Also, albumin is a prognostic marker, tells us about mortality risk,
but does not help us to select a patient that will or will not respond.
Now, the marker that actually showed the most promise regarding responsiveness to treatment
was actually inflammation. And so within all our patients, we measured C-reactive protein,
which is an inflammatory protein. And here, you see the stratified analysis, where overall,
we had this nice benefit from the intervention regarding mortality within 30 days. And we
found the same benefit in low-inflammation and moderate-inflammation patients. But in
these patients with a C-reactive protein higher than 100 (so highly inflamed patients), you see
that these two curves here turn and there was no more benefit regarding nutritional intervention
for mortality reduction. And this was highly significant also in the interaction analysis.
So, in summary, I think there is increasing evidence today that malnutrition is a strong
risk factor but also a modifiable risk factor. And we have to be active in our patients in the
hospital. We need to do proactive screening and start nutritional support protocols to
reduce the high mortality and complication rate. However, I think in the future, we need to better
differentiate between diagnosis and treatment response. And the screening tools we use today,
there are more diagnostic prognostic tools, and they are not necessarily telling us about
treatment response. And so I think here in the future, we need to do more interventional studies,
interventional trials, to really understand what are the parameters that tell us a patient
will respond to nutritional intervention and, more specifically maybe, which patient needs which type
of nutritional support. And with that, I'd like to close. And thank you again for your attention.
DR. PATRICK STOVER: It's a pleasure to be with you today to talk about causes, consequences,
and treatment of micronutrient deficiencies over the next 10 minutes. And please note that I'm
going to be talking about deficiencies associated with diseased populations (those you would find in
the clinic) rather than healthy populations. And I would like to start with this workshop report
from the National Academy of Sciences a few years ago talking about special nutritional needs. That
is what...describing the evidence that we have to date on how the disease processes themselves can
alter nutritional needs. And, of course, this is an important question because as of 2014, it was
found about 60% of U.S. adults suffer from a chronic condition, 40% by more than one chronic condition.
And so what this workshop does was really review the evidence for special nutritional requirements
in disease states and medical conditions that can't be met with a normal diet. And so the
workshop addressed that following list below of conditions where, in fact, we do have evidence
that disease can alter nutritional requirements. Now, this idea that disease processes affect
nutritional requirements goes back to the early 1970s and work by Victor Herbert.
But what he talked about was how disease related etiology, whether it's inflammation, genetic
predisposition, autoimmunity, mitochondrial dysfunctions, pharmaceuticals, trauma,
or the combination of these impact physiological functions that then impact nutrients and their
function. They can affect gut absorption. They can affect the brain nerve barrier. You know that
certain nutrients are concentrated several fold across the blood brain barrier, and loss of that
concentration of nutrients in the brain can result in disease. It can cause increased degradation and
turnover of nutrients, altered excretion patterns, altered metabolism, altered tissue distribution.
And these physiological changes then can impact both human nutrition resulting in
whole-body nutrient deficiencies or sometimes tissue-specific nutrient status. That is,
the disease process that's isolated to a certain tissue can experience deficiency of
nutrients in the absence of whole-body deficiency. We can get new conditionally essential nutrients.
We can get new nutrient toxicities. And, of course, during the regenerative phase of recovery
from chronic disease, we have to worry about stem cell and stem cell nutrition, which have different
nutritional requirements from differentiated cells. We also know that disease, independent
of its effect on human nutrition, can also impact biomarkers that we use to assess nutrient status
and function. And so, we have to be mindful that when we see a change in these biomarkers in
disease, it may not necessarily mean that actual nutrient status or nutrient requirements differ.
So, in this slide, this just illustrates the challenges of establishing special nutritional
requirements. To the left in blue, you see healthy populations, where we derive dietary
reference intakes to meet their nutritional needs using various types of biomarkers that are
listed there. Looking at a whole body, nutrient status, function, clinical outcomes. You see to
the right in red though, we have about half of the adult population that has a chronic disease.
And not only do we have to understand nutrient status in the relevant biomarkers that we do
for healthy populations, but we have to consider other considerations, like
tissue-specific nutrient status, like restoration of function through tissue regeneration that may
prescribe, if you will, different nutrient requirements. So, a few factors that we know
actually affect nutrient status and/or biomarkers of status and disease. One, in some diseases we
see increased rates of nutrient catabolism. One of the most studied examples of this is acquired
Arginase Deficiency Syndrome, where in certain disease states, or as a result of trauma in cancer
or surgery, you actually see an increase in the expression of the enzyme arginase that
then begins to degrade all of the arginine. When this happens then, the patient becomes deficient,
if you will, in that amino acid, and, in fact, their recovery is much improved if they are given
supplemental arginine. We also see the disease can affect tissue redistribution and/or excretion.
We know that infection affects iron levels in the plasma and biomarkers of iron levels. Now, does
this redistribution mean a change in requirement? That's still an open question. We also know that
inflammation can affect tissue distribution of vitamin B6, where it disappears from plasma,
vitamin D, and others. So, you see here where you can get a redistribution effect due to a disease
or an infection, whether or not that actually is a nutritional deficiency remains an open question.
We see decreased uptake across barriers, including the gut barrier, but also the blood/brain barrier,
which again concentrates certain nutrients in the brain. And this can be caused by genetics,
inflammation, drug use, autoimmunity, and others. But we see in bariatric surgery that following
bariatric surgery, deficiencies in vitamins, including B12, B1, AKC,
and folate, are not uncommon, and, in fact, some supplemental quantities of these micronutrients
are required to maintain nutritional status. We see the same with the minerals that are listed.
Similarly, in IBD and other inflammatory conditions in the gut,
we also see nutrient deficiencies that result from that disease process.
We also see when enduring regenerative phases following chronic disease or following injury,
we have to expand our stem cell populations and we're having increased evidence that in
fact stem cells have different nutritional requirements from fully differentiated cells.
The Thalacker-Mercer Lab recently published a paper that showed that myoblasts have a requirement
for serine and glycine. They do not synthesize sufficient amounts for myoblast proliferation and
differentiation, and so therefore, they have a special requirement for those amino acids.
We also know that drugs can alter nutrition needs. There was a study a couple of years ago that
showed that the ACE inhibitor drug Enalapril is more efficacious when it's used in combination
with supplemental folic acid. It's also known that when this drug is administered in the
absence of folic acid, it actually affects plasma folate levels and biomarkers of folate function.
It's not known how this occurs, but you can see the the drugs can alter nutrient
requirements. Sometimes their efficacy can affect can be affected by nutrients.
SPEAKER: However, this is not considered a special nutritional requirement where
the FDA mandates that when a drug does have an effect on nutrition,
that that extra nutrition support, if you will, be administered with the drug.
So, we can learn a lot about special nutritional requirements from the long history of work done on
inborn errors of metabolism, where medical foods have been formulated with different concentrations
of nutrients or addition or subtraction of certain metabolites to overcome the genetic
deficit associated with that inborn error of metabolism. And the open question is,
in chronic disease, can we take the same approach, where chronic disease results in a loss of
function? And can we understand that a systems level how those nutritional needs are different?
This is an example we see from the inborn error of metabolism,
where you have cerebral folate deficiency due to either mutations in the folate receptor,
you can see there, or due to mitochondrial dysfunction, or due to autoantibodies, you end
up getting a deficiency of folate in the brain. This can be overcome with very high-dose folate
and a particular form, that is folinic acid. Folic acid itself will not restore brain levels. So
again, we have good examples of how to approach these sort of special nutritional requirements.
Do we have frameworks to establish them? Absolutely. I think many of you are probably aware
of this framework that was published some years ago by Russell. But we can look at exposures,
nutrient exposures, and we can directly connect them to a clinical outcome in either a healthy
or a disease population. We also need to establish validated surrogate outcomes that aren't affected
by the disease, but that respond to the nutrient exposure and then report on what that clinical
outcome is going to be. We also can, again, continue to look at indicator of status
biomarkers that then connect to the clinical outcome that again are independent of the disease
process as well as nonvalidated markers. So, in conclusion, we do have gaps in future directions.
One real need is to develop system biomarkers that really link disease to nutritional needs, both in
healthy populations and unhealthy populations. If we understand what systems are affected,
what nutrients are affected with those systems, we can systematically then be able to prescribe how
to rejuvenate those systems in the disease state and do it in a way that is low cost. We have to
remember that status and functional biomarkers in disease don't necessarily indicate true whole-body
deficiencies. Sometimes the disease itself is just modifying the marker without really
affecting nutrient status, and sometimes we have to consider tissue-specific deficiency and whether
or not we have markers to report on those as opposed to a whole-body or systemic deficiency.
We have to remember that disease comorbidities may be due to disease-induced nutritional
Deficiencies. That is, for example, you have the disease of diabetes that can lead to peripheral
neuropathies. Well, there's some evidence, in fact, that peripheral neuropathy results from
a alteration in nutrient needs caused by diabetes itself. There's strong animal literature for that.
We have to understand that the cause of deficiency and that's going to be important
because it may indicate what form of nutrient is needed in disease.
We see this in the case of folate. We also see it in the case of vitamin A and other nutrients
where the disease may dictate a specific form of the nutrient that works as opposed to others.
And we also have to remember that sometimes you can have a true nutritional deficiency caused by
disease and supplementation may not resolve that deficiency, such as what you see in pernicious
anemia and vitamin B12. So with that, I thank you very much for your time and attention.
DR. KATHERINE TUCKER: Good afternoon. I've been asked to talk about the nutritionally vulnerable and hidden hunger.
As we've been hearing today, malnutrition is common in hospitalized patients,
and screening is often inadequate. There are different definitions of malnutrition.
The European Society for Parental and Enteral Nutrition considers fat-free mass as a central
component. The American Society considers any two of the following: weight loss, low energy intake,
handgrip strength, loss of muscle mass, loss of subcutaneous fat, or fluid accumulation.
I checked in our local hospital and found that the screening tool that they're using
selects the two easiest of these: have you recently lost weight without trying,
and have you been eating poorly because of decreased appetite?
Although this is good to be screening for malnutrition in this way,
what it's unlikely to catch in many cases is sarcopenic obesity. And we know now that with the
growing prevalence of obesity in our population, that sarcopenic obesity is also increasing.
These data from the NHANES III, which is now quite old, where the
prevalence of sarcopenic obesity-defined as a combination of obesity and low muscle mass-
the prevalence in men was about 10% and women 7%.
However, this has been increasing rapidly since that time, and recent estimates show
that it may affect more than 23% of those over 75 years of age. And we know that sarcopenic obesity
poses patients at risk of frailty, disability, morbidity, and mortality. One study showed that
survival time was significantly lower among adults aged 50 to 70 with sarcopenic obesity.
The trick is that this requires measurement of muscle mass,
either by DEXA or bioelectrical impedance, and this is rarely done.
Beyond muscle wasting itself, malnutrition in hospitalized patients takes the form of
micronutrient deficiencies. And you've just heard a little bit about that.
In this case, this is the NHANES dietary intake data showing that most older adults
have low intakes of critical nutrients, including dietary fiber, vitamins, and minerals.
Why is this important to consider in hospitalized patients? Well, in addition to protein, which is
associated with loss of muscle mass and decreased immunity, N-3 fatty acids and dietary fiber are
both related to inflammation, and vitamins and minerals are associated with wound healing,
resistance to infection, diabetes control, anemia, and other conditions.
The Mini Nutritional Assessment tool is a tool that's been very commonly used throughout the
world, and I like it because it includes in its full form questions about diet,
questions about protein foods, and about fruits and vegetables. Although
the long form is not that long, it still takes a little bit of time,
so they have created a shorter form, which unfortunately does drop the dietary questions.
Dietary screening remains important, however, particularly for these micronutrients. And
so I was involved in the early stages of development of the Geisenger Rural Aging
Study Rapid Dietary Screening Tool. This tool has 25 food and behavior related questions,
and it's been validated, one, by looking at dietary patterns created from those answers,
which showed significant associations between a healthy diet with higher HDL cholesterol and
physical activity and lower serum triglycerides and waist circumference, and with a Western
or poor diet, which was significantly associated with lower serum vitamin B12.
It's also been validated against a healthy eating index, which was derived from three 24-hour
recalls, and that showed that the DST score correlated significantly with HEI and that those
at risk from the DST score had significantly lower HEI scores than those not at risk.
The DST score was also significantly associated with serum carotenoids
and importantly with 8-year mortality,
24% reduction in risk among those with the high score versus lower. These are the questions on the
score. I apologize, this isn't terribly clear, but basically there are questions like how often
do you usually eat fruit as a snack? Do you drink some kind of juice? How often do you eat carrots,
sweet potatoes, broccoli, or spinach? And each of these has a point value.
A patient is considered at risk if the score is less than 60.
So, in addition to dietary intake scores, how do we identify those that are most nutritionally
vulnerable with hidden hunger? Well, one of the key indicators of this is food insecurity.
Food insecurity is estimated to affect more than 15 million households in 2017. It's part
of the social determinants of health, which are gaining steam as something to investigate
in order to evaluate risk. Of course, these social determinants tend to be most problematic in those
with low income, certain minority groups, or single parent households. And food insecurity has been
associated clearly with higher risk of diabetes and diabetes control, hypertension, dyslipidemia,
depression, and cardiovascular disease. Screening is recommended. It's ideal to use a standard
18-item questionnaire, which has been well validated and tested, but two questions have
been identified which show good sensitivity and specificity. These include simply asking, within
the past 12 months, were you worried that food would run out before you got money to buy more?
And was the food you bought lasting, and and did you have enough money to get more if needed?
Patients identified as food insecure should be connected with food assistance programs, as when
they returned home after hospitalization. This can make a large difference.
As an example, we looked at food insecurity in our study in Boston,
Puerto Rican adults age 45 to 75. We found that 17.4% were food insecure.
Factors associated with food insecurity included medium acculturation versus higher or lower-
interestingly, those that were trying to live in both Spanish and English,
living far from a supermarket, and low availability of nutritious foods.
Food insecurity was significantly associated with dietary quality,
particularly with lower vegetable intake, with poor glycemic control among those with diabetes
and with cognitive decline over two years, particularly in executive function.
So in conclusion, nutrition screening is critical for patient care but is
not always conducted. Further, it's important to move beyond wasting as the main criteria
as many vulnerable patients are obese but still sarcopenic. Micronutrients cannot be ignored as
intakes are insufficient in large segments of the population and brief dietary screeners can help.
Finally, food security is a key indicator of risk and a point for action. Thank you.
DR. DAVID SERES: Thank you all for a really robust session and
some very interesting topics. Dr. Tucker, on your food insecurity measures, have you
gotten to the point where you do any studies on interventions to see if these affect outcomes?
DR. KATHERINE TUCKER: Yes, actually, we're in the process of planning a study right now to provide meal kits to people
in the communities with food insecurity and to see how that affects their health.
DR. DAVID SERES: Excellent. Can everybody please turn on their cameras,
it's separate from the microphone. Thank you. Alright, a couple of other questions for Dr.
Stover. Are there micronutrients of concern with respect to deficiency in the healthy population?
DR. PATRICK STOVER: Thank you very much. The answer to that is they're certainly not common, at least in
most industrialized Western nations. Although that just said, there was a very interesting study that
should be published very soon in the American Journal of Clinical Nutrition that showed,
in fact, in Ireland, where they used a gold standard method of detecting riboflavin status,
one that's normally not used, found significant deficiency of riboflavin in the population. And
this actually had cascading effects on other micronutrients because of the role of riboflavin
cofactors in processing these other vitamins to become cofactors. So while they are not
common and most of these are avoided through various fortification policies that we have,
there are some that are unrecognized.
DR. DAVID SERES: So while we're sort of on that, there are a couple of questions both for you and for
Katherine Tucker about including micronutrients in these assessments. Any thoughts on that?
DR. KATHERINE TUCKER: Well, as I as I said, I think it's really important. I think that there
are a lot of people that may not have the frank deficiency diseases, but I think
large segments of our population have subclinical micronutrient deficiencies. And if they come into
the hospital with that predisposition, that they are going to do even worse in terms of outcomes.
I think there needs to be a lot more focus on micronutrients, personally.
DR. DAVID SERES: OK, Dr. Schuetz, can you tell us what's different about your nutrition
risk score such that you actually were able to predict response? What's different about
that compared to all of these others that you've shown do not predict response?
DR. PHILLIP SCHUETZ: Yeah, well, I think as discussed in one of the earlier talks,
most of the nutritional assessment and risk scores use kind of the same variables. So
they look at the weight and appetite, BMI and I think all these variables, they are pretty good
outcome predictors. Now in our analysis, we actually found that the strongest
predictor for nutritional support were in fact inflammation. So, that was pretty interesting
because we didn't know that inflammation is an important key driver for malnutrition. And if
you have a patient with chronic inflammation, the risk of this patient to become malnourished and
develop cachexia is much increased. But I think what was interesting in our data was to see that
actually inflammation was negatively associated with the response to treatment. So this goes back
to the old discussions we had, that patients with cachexia seem to have less pronounced response to
nutritional interventions compared to patients with earlier or different types of malnutrition.
And so I think that's very important that today we talk about malnutrition in
patients that actually present with very different phenotypes of this condition.
DR. DAVID SERES: Yeah, you and I have talked about this. I was actually surprised that these other scores,
which depends so heavily on inflammation, the phenomena of inflammation like edema and so
forth, that they were not negatively predictive, they were just not predictive; I would have
expected them to be negatively predictive. So this is an area that I think is really ripe for
research. Char, and I apologize for going back and forth with first and last names,
but I since I know you all, you mentioned that, sorry, the GLIM and A&D were validated to predict
SGA scores and so forth, but just to verify that they have not been validated
to predict response to nourishment, that's correct, right?
DR. CHARLENE COMPHER: Yeah, it is correct. Sadly,
they have not been yet, but that needs to happen and needs to happen soon.
I'd like to just follow up on something Dr. Schuetz just said that's in this line.
I really liked your description of a strategic identification of groups among a large group of
patients who will some will benefit, some may have no benefits, some may have harm.
In your observations about the degree of inflammation, those with the highest inflammation,
did they have harm or they just did not have the same benefit? DR. PHILIPP SCHUETZ: Yeah, that's an excellent
question. So in our data, we had rather absence of benefit. However, when you look closer at
the intensive care data and there are some large trials showing that you do overfeeding
of patients is actually associated with adverse outcomes. So, the EPaNIC trial is this large
trial from Belgium where they actually found that mortality and lengths of ICU stays increased if
you use parenteral nutrition with very high doses of calories and protein in patients that are very
severely metabolically stressed. So I think in the end the patients that are metabolically stressed,
highly inflamed, and you give those patients too much nutrition, I think you can actually do harm
in these patients. And we know today that we have re-feeding, but also overfeeding and possibly
interaction with autophagy, are all mechanisms that have been discussed that could explain
why these patients hurt if you use too much nutrition in a metabolically stressed patient.
DR. DAVID SERES: Great. Patrick, do you have any suggestions for clinicians
as a practical matter? How do you know whether or not you can trust the level
of something if indeed all of these levels are affected by inflammation and so forth?
DR. PATRICK STOVER: Certainly. Well, I mean, this is an area where we certainly need a lot more
research. There's been good work that has been done trying to correct iron status
for markers of inflammation. There have been tempts to do this with vitamin B6,
but by and large, we need to understand the functioning across the board of biomarkers,
of micronutrient status and function, and whether or not they still hold true in states of disease.
And so there's just a tremendous amount of work that needs to be done. Again,
iron is one where there have been great inroads that have been made. But we need to understand is
this a precision approach we have to take or can we actually classify certain diseases specific way
and then have separate subgroup requirements for that group when they are in that disease state.
And as has been mentioned, there's also the issue where, in disease, some people can do harm
with increasing levels of a micronutrient that are meant to control for a deficiency,
so a disease-induced deficiency. So, there is just a lot of work that has to
be done in this area. I thought that the workshop that the National Academy did in 2018 before the
pandemic was a good start, but it's certainly an area where we just need a lot more research.
DR. DAVID SERES: Dr. Tucker, are you close to having a sense of the impact on hospital
outcomes, on what is food insecurity doing to that? Do we have any of that kind of
data directly looking at do people with food insecurity do poorly in the hospital?
And then subsequently we talked about that and that's wonderful that you're intervening.
But do you have anything that sort of says that it's predictive of poor outcomes in the hospital?
DR. KATHERINE TUCKER: Right now there is a ramp-up in interest in food
insecurity, and there's a lot of research going on right now. It's been well funded
and it's very important. Most of it has been in the community, honestly.
There has not been a lot of food insecurity screening at the hospital level.
DR. DAVID SERES: Yeah, I'd love to see it translated across...
DR. KATHERINE TUCKER: I do know of... I am working with someone who is using AI with hospital records and
they're trying to pick up food insecurity along with other social determinants of health, working
with the large veterans data to see if they can predict some of these outcomes as well. I think...
DR. DAVID SERES: So somebody is... I'm sorry.
DR. KATHERINE TUCKER: No, I just think there still needs to be a lot of research to clarify these things.
DR. DAVID SERES: Someone asks, and I think this is for Dr. Schuetz. Are there those with a CRP
greater than... Are those with a CRP greater than 100 actually refractory to nutrition support?
In other words, they're asking is this a sign for futility?
DR. PHILLIP SCHUETZ: Yeah, well, it's kind of hard to understand the data, really. And sometimes people
ask me, well, what do you do with a patient with a very high CRP level that is highly inflamed? Are
you just not going to feed this patient, although he's malnourished, right? And I think that's a tough question.
So, I think in the end, we don't know how to best respond to the signal. But it's
a very strong signal in the data that patients that are highly inflamed just
seem to respond differently. And so maybe we need to use a different type of nutrition.
And we know there is some types of nutrition that seem to modulate the inflammatory response. So
immunonutrition or also some types of lipids, omega three lipids, and other sorts that are
also clearly in the Mediterranean diet that may be beneficial for these patients. But personally, if
I have a patient that is highly inflamed, I just try to go very slow with this patient population.
And I just try not to be too eager to reach the nutritional goals too fast. So typically,
I would just start very slowly in these patients. And typically, if the patient responds to whatever
we do, if you give antibiotics or treatment, and typically we see that the inflammation will come
down during the hospital stay. And so gradually we can then increase the nutritional intake.
But this is just my personal view. I think the higher the inflammation, the more we have to be
cautious and go slow with the nutrition just to prevent doing any harm to these patients.
DR. DAVID SERES: Yeah, I think we'll be talking about the Moonshot study that needs to be done. And
one of the things I think that might come out of this would be to look...to see the trend if
the C-reactive protein or other markers stay high, I would predict that those patients
wouldn't respond as well to those who have a C-reactive protein that drops, because the ones
who have the C-reactive protein that drops are getting medically better. So I would...
yeah. Anyway, these are some of the really good questions that...
DR. PHILLIP SCHUETZ: It's very, interesting, and this is also new talk. I think it's very strongly
correlated between also the severity of disease, response to treatment, and
also response to nutrition. It's all kind of interacting to each other. And I don't think
we have the perfect markers today. C-reactive protein may be one marker of inflammation,
but there's maybe there's also other markers that can help us to understand if a patient is
metabolically stressed, if he's ready to actually receive nutrition and what type of nutrition.
DR. DAVID SERES: And similarly, I think what Patrick was saying earlier is that we need to find some sort
of a marker. And you were speaking specifically about the micronutrient levels and function,
but in general markers that are not responsive to the disease,
that can tell us whether or not we're nourishing adequately or not. And maybe
those are far out there. But I think that's really what we're all hoping for would come. Let's see.
So, Charlene, could you speak a little bit about, there were some questions before
about the preference of ASPEN A&D, I mean, yeah, ASPEN A&D versus GLIM and so forth.
Can you address the relationship between the two approaches just so that people can understand?
DR. CHARLENE COMPHER: Sure. It always amazes me when this question comes up, and it does come up regularly
when I present about GLIM. GLIM was designed to be an umbrella that the SGA could fit under, the
Academy ASPEN can fit under, the European approach can fit under. We're all using the same criteria.
We needed not to have people walk away from the SGA if they have fully integrated the SGA
into their medical system and it's in use. But we want to use GLIM as a common language so that we
can make comparisons across the SGA, the Academy ASPEN, and all of the other approaches that are
used. The same criteria are used, the same weight loss criteria are used for moderate
and severe in most cases. In the U.S., we are not going to use low BMI as an identifier for
undernutrition very frequently. Maybe 5% of our population has a low BMI. and we will see
those in the hospital. But there are so much more going on with them that the fact that the Academy
ASPEN does not have BMI and GLIM does is really a minor point. They're really one and the same
and if you document one, you've essentially documented the other.
DR. DAVID SERES: I will also comment that, we were talking earlier about reimbursement
for malnutrition that if there's not a low albumin below a certain level,
it's my experience that most of the patients that we diagnose with severe malnutrition,
unless they are not medically ill, are going to have a low albumin. So I think that it's...
because it's so prevalent that our patients are inflamed. Let's see. While we're talking
to you Char, what do people mean when they're talking about nutrition-sensitive outcomes?
DR. CHARLENE COMPHER: I think that's an important question. And I'd like to say one more thing about outcomes
after I address this question. I think Dr. Schuetz is trying to get at nutrition-sensitive outcomes.
He's looking at the fact that the nutrition indicators are largely prognostic, but they
don't predict the response to feeding, which from what he's shown so far, inflammation does.
We look at outcomes of mortality because it's clear. We look at length of stay, and we look
at re-admissions. We look at length of stay and re-admissions because they matter to the
hospital's bottom line. If we have long lengths of stay, then some other patient can't come in
to the hospital because the bed is not available. If we have re-admissions, we have to have the bed
space. Those are outcomes that are of value to the overall system. They may mean much less to
patients than, yes, they matter, mortality clearly matters to patients. But what matters to a patient
about the quality of their life? What would make a difference to a patient in terms of his outcomes?
I suspect that nutrition-related outcomes and feeding outcomes
are going to be probably more diverse and more on the chronic level
than mortality and length of stay and re-admissions. And the problem with looking
at mortality in particular, in order to show differences in mortality, you need a massive
sample size. For the other effort trial comparing protein dose In critically ill
patients, we needed a sample size of 4,000 ICU patients to show a difference in mortality.
When you need 4,000 patients, it's very hard to do the kind of sub analysis that Dr. Schuetz is
talking about, finding the groups, the group of patients who benefited, the ones who didn't
benefit, and the ones who had harm. It's also harder to enroll patients with malnutrition.
It's hard to find, if only somewhere between 20%, 40% of your population has malnutrition,
how long is it going to take you to enroll a sample size of 4,000 so that you can determine whether
there's a mortality difference or not? I think that we need to look at different,
a broader array of clinical outcomes that are associated and see which ones
are the ones that we can really use to know whether feeding made a difference or not.
DR. DAVID SERES: Yeah, I think that this is one of the really most important research questions is how
do we measure the effect? Because really the only outcomes are mortality, quality of health
or cost of health care, lengths of stay, things like that, complications, and quality of life,
none of which are really easy to measure in smaller groups especially. But really are
the things that matter. And all of our focus on surrogates to date...things like albumin and so
forth...relate to outcome but don't relate to the nourishment. And so, we need to find that bridge, if
we can for something that would take care of all of that. So we have just a couple of minutes left.
There was a question for Patrick about inclusion of micronutrients in measures like GLIM and so
forth. Any thoughts about that?
DR. PATRICK STOVER: Sure. It just goes back to points I made previously, and that is, can you classify
the population based on a particular aspect of a disease state that would then inform whether
or not they have a deficiency and if they are going to be responsive to increased exposure to that
nutrient. And so, we don't have that right now. We do know, again, in particular patient populations,
there are studies that have shown effects, but they haven't been done in a systematic
way that really builds an evidence base for this. So, I mean, the two challenges are one,
can we classify specific diseases or disease subtypes, two, alter nutrient
needs? And that's really the challenge with, again, with the biomarker that you aspire to.
DR. DAVID SERES: Yeah, certainly. I know that I have certainly struggled with the term deficiency
over the years because so many nutrients are altered by their disease. Critical illness,
for instance, will lower your vitamin D level, but it's most likely because your vitamin D
carrier protein drops, not because you have a deficiency. But if you look at the, well,
there is a longer story to this, but there are now some 1400 papers on COVID and Vitamin D,
all of the observational studies showing very strong relationships between D levels and outcomes
with COVID, which only says that the sicker you are, the lower your D level is rather than the
other way around. But suffice it to say that this is part of the reason for this session in
particular about renaming malnutrition. Some years ago when Gordon Jensen got up to announce the new
guidelines, I raised my hand in front of several hundred people. I said, "hey,
Gordon, can we call it something else? Can we please call it Matilda? Because every time you
say that a patient with malnutrition is malnourished, you might be wrong."
So ,on that note, I think we're about out of time. I want to thank everyone who has
participated. Thank you all. We have a kudos in the question box. Thank you, Elizabeth, and
look forward to tomorrow's session. We'll start off with a wrap-up of what happened today, and then
we'll go into some of the talks that I mentioned about body composition and disease-specific
cachexia studies to try and sort all of this out. And look forward to seeing you tomorrow.
DR. PATRICK STOVER: Goodnight. Thank you.