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Consensus Statement
ABSTRACT
The Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommend
that a standardized set of diagnostic characteristics be used to identify and document adult malnutrition in routine clinical practice. An
etiologically based diagnostic nomenclature that incorporates a current understanding of the role of the inammatory response on
malnutritions incidence, progression, and resolution is proposed. Universal use of a single set of diagnostic characteristics will facilitate
malnutritions recognition, contribute to more valid estimates of its prevalence and incidence, guide interventions, and inuence
expected outcomes. This standardized approach will also help to more accurately predict the human and nancial burdens and costs
associated with malnutritions prevention and treatment, and further ensure the provision of high quality, cost effective nutritional care.
J Acad Nutr Diet. 2012;112:730-738.
M
ALNUTRITION IS MOST Those adults who lack adequate calories, to those with non-severe (mild to mod-
simply dened as any protein, or other nutrients needed for tis- erate) malnutrition that if left unrecog-
nutritional imbalance sue maintenance and repair experience nized and unaddressed is likely to prog-
(1). People suffer from undernutrition. In acute, chronic, and tran- ress to a severely malnourished state
overnutrition when they consume too sitional care settings, recognition and (3-11). Although various laboratory
many calories. Although the focus of treatment of adult undernutrition is a pri- tests and physical signs or symptoms
this consensus statement is adult un- mary concern (3,7-10). For the purposes of have been suggested as potential mark-
dernutrition, we cannot fail to recog- this discussion, therefore, the term adult ers for inammation, and some are
nize the enormous impact that obesity malnutrition shall be synonymous with briey mentioned in passing in this
has on both personal and national adult undernutrition. document, the Academy of Nutrition
health and rising health care costs (2). Adult undernutrition typically occurs and Dietetics (Academy) and the Amer-
Even overweight or obese adults who along a continuum of inadequate intake ican Society for Parenteral and Enteral
develop a severe acute illness or expe- and/or increased requirements, im- Nutrition (A.S.P.E.N.) do not propose
rience a major traumatic event are at paired absorption, altered transport, any specic inammatory markers for
risk for malnutrition and frequently and altered nutrient utilization. Weight diagnostic purposes at this time.
need and benet from intensive nutri- loss can, and frequently does, occur at Malnutrition is a major contributor to
tion intervention (3-6). multiple points along this continuum. increased morbidity and mortality, de-
Individuals may also present with in- creased function and quality of life, in-
ammatory, hypermetabolic, and/or creased frequency and length of hospital
This article is simultaneously published in hypercatabolic conditions. Inamma- stay, and higher health care costs (2,7-
the May 2012 issues of the Journal of the tion is increasingly identied as an im- 11). Jensen and colleagues propose an
Academy of Nutrition and Dietetics and the
Journal of Parenteral and Enteral Nutrition. portant underlying factor that in- overarching denition of malnutrition as
creases risk for malnutrition, and that decline in lean body mass with the po-
may contribute to suboptimal response tential for functional impairment at
Copyright 2012 American Society for
Parenteral and Enteral Nutrition and the to nutrition intervention and increased multiple levelsie, molecular, physio-
Academy of Nutrition and Dietetics risk of mortality (7-9). As such, individ- logic, and/or gross motor (8). The diagno-
2212-2672/$36.00 uals may exhibit a wide range of char- sis of malnutrition in a patient is an un-
doi: 10.1016/j.jand.2012.03.012
acteristics from severe malnutrition deniably complicating condition that in
many cases signicantly increases re- primary diagnostic indicators of adult listed in the ICD-9 CM (Clinical Modi-
source utilization in the acute care set- malnutrition (15-20). The Academys cation)262, Other severe, protein-cal-
ting beyond that experienced by the pa- Evidence Analysis Library (EAL) ana- orie malnutrition; 263 (263-263.09),
tient in nutritional health (7-11). lyzed reduction and/or change in se- Other and unspecied protein-calorie
Our purpose is to dene malnutrition rum albumin and prealbumin with malnutrition; and additional code sets
for adults in all settings. In the absence weight loss in prolonged protein en- also listed in the Endocrine, Nutritional,
of data showing that malnutrition ergy restriction, anorexia nervosa, non- and Metabolic Immunity Section that re-
should be dened differently in differ- malabsorptive gastric partitioning bari- late to specic micronutrient decits
ent settings, the Academy and A.S.P.E.N. atric surgery, calorie restricted diets, may continue to be used in documenting
have adopted patient-specic deni- starvation, low-calorie diets, and nitro- observed adult nutrition decits (27).
tions based on etiologies including so- gen balance (22-24). The analysis indi- According to most recent data avail-
cial and environmental circumstances, cated that these acute-phase proteins able (2009), only 3% of patients admit-
chronic illness, and acute illness. The do not consistently or predictably ted to acute care settings in the United
distinction between acute and chronic change with weight loss, calorie re- States are diagnosed with malnutrition,
illness is based on time (the National striction, or nitrogen balance (22-24). and the primary ICD-9 code being used
Center for Health Statistics [NCHS] de- They appear to better reect severity of is 263.9, Protein-Calorie Malnutrition,
nes chronic as a disease or condition the inammatory response rather than NOS (not otherwise specied) (28). Dis-
that lasts 3 months or longer) (12). The poor nutritional status (7-9). These labo- cussions regarding revisions to the cur-
Academy and A.S.P.E.N. propose etiolo- ratory tests, while probable indicators of rent language, to make it consistent
gy-based denitions that consider time inammation, do not specically indi- with an etiologically based malnutri-
and degree of inammatory response cate malnutrition and do not typically tion diagnostic nomenclature, are on-
in categorizing an illness or injury as respond to feeding interventions in the going. CMS has also questioned the use
acute vs chronic (7-9). setting of active inammatory response of acute-phase serum proteins as pri-
(7-9); therefore, the relevance of labora- mary diagnostic criteria for malnutri-
tory tests of acute-phase protein levels, tion since studies (22-24) increasingly
NEED TO STANDARDIZE suggest limited correlation of these
CHARACTERISTICS TO as indicators of malnutrition, is limited.
In 2007, the Centers for Medicare and proteins with nutritional status.
DIAGNOSE AND DOCUMENT
ADULT MALNUTRITION Medicaid Services (CMS) resequenced
its prospective payment system (the THE ACADEMY AND A.S.P.E.N.
Adult malnutrition is a common but
frequently unrecognized problem Diagnostic Related Groups) into a hier- COLLABORATE TO
whose incidence and prevalence are archical system called the Medicare Se- STANDARDIZE THE DIAGNOSIS
difcult to determine (8). In 1996, The verity-Diagnostic Related Groups (MS- OF ADULT MALNUTRITION
Joint Commission mandated that nutri- DRGs) that reects the presence or In 2009, the Academy and A.S.P.E.N.
tion screening be accomplished within absence of complications and/or co- recognized the need to standardize the
24 hours of admission (10). This re- morbidities (25). The MS-DRGs are pay- approach to the diagnosis of malnutri-
sulted in the identication of multiple ment groups designed for the Medicare tion in adults and to coordinate these
criteria and development of a number population. Patients with similar clini- efforts among their respective organi-
of different approaches to the identi- cal characteristics and similar costs are zations. Current approaches to the di-
cation of malnutrition in hospitalized assigned to an MS-DRG that is linked to agnosis of malnutrition vary widely,
patients that were not always evi- a xed payment amount based on the specically with regard to the diagnos-
dence-based (13-21). Thus, there is cur- average cost of care for patients in the tic criteria used, and there is generally
rently no single, universally accepted group. Since the designation of malnu- poor specicity, sensitivity, and inter-
approach to the diagnosis and docu- trition as an MS-DRG, CMS has voiced observer reliability among the current
mentation of adult malnutrition. Cur- concern about the inappropriate use of protocols in use (7-9). This lack of na-
rent estimates of the prevalence of certain malnutrition codes and the tional standardization of diagnostic char-
adult malnutrition range from 15% to wide variation in prevalence/incidence acteristics results in widespread confu-
60% depending on the patient popula- of malnutrition within the same geo- sion and potential misdiagnosis. Also,
tion and criteria used to identify its oc- graphic area and/or populations with many current screening and assessment
currence (13). Diagnostic elements in similar demographics (26). In Septem- protocols fail to appreciate the role of the
malnutrition screening protocols vary ber 2010 and March 2011, the National inammatory response on acute-phase
widely and range from a simple assess- Center for Health Statistics (NCHS) re- proteins that are often used as primary
ment of appetite and unintentional quested and received commentary indicators of nutritional status (8,29). The
weight loss (14) to more complex pro- from the Academy/A.S.P.E.N. on the ap- presence of inammation can blunt a fa-
tocols that include measurement of a propriateness of the existing malnutri- vorable response to nutrition interven-
variety of anthropometric and labora- tion codes descriptors and use. Pro- tion and increase the level and magni-
tory parameters (15-21). posed revisions to the existing code tude of human and nancial resources
A number of the more complex pro- structure and language were made at needed to restore the patient to optimal
tocols that have been developed to de- the International Classication of Dis- health (7).
tect malnutrition in adults rely on ease, 9th edition (ICD-9) Coordination In 2009, A.S.P.E.N. and the European
changes in acute-phase proteins such and Maintenance Committee hearings Society for Clinical Nutrition and Me-
as serum albumin and prealbumin as but were not accepted. The codes sets tabolism (ESPEN) convened an Interna-
May 2012 Volume 112 Number 5 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 731
FROM THE ACADEMY
Figure. Etiology-Based Malnutrition Denitions. Adapted with permission from reference (8): Jensen GL, Bistrian B, Roubenoff R,
Heimburger DC. Malnutrition syndromes: A conundrum vs. continuum. JPEN J Parenter Enteral Nutr. 2009;33(6):710-716.
tional Consensus Guideline Committee characteristics to detect and diagnose may sometimes mask weight
to develop an etiology-based approach malnutrition should have the following loss; and
(8) to the diagnosis of adult malnutri- attributes: be few in number (basic hall- diminished functional status
tion in clinical settings (see the Figure). marks), support a nutrition diagnosis, as measured by hand grip
The recommended approach was then characterize severity, change as nutri- strength (3,36,38-42).
endorsed by A.S.P.E.N. and ESPEN. The tional status changes, be evidence-
Academy accepted these denitions The characteristics, as listed in the
based when possible or consensus-de- Table, distinguish between severe and
developed to describe adult malnutri- rived, and be able to change over time
tion in the context of acute illness or non-severe malnutrition. The charac-
as evidence of validity accrues. Since teristics listed are continuous rather
injury, chronic diseases or conditions,
there is no single parameter that is de- than discrete variables. There is insuf-
and starvation-related malnutrition.
nitive for adult malnutrition, identi- cient evidence regarding their applica-
cation of two or more of the following tion in clinical settings to allow for fur-
CHARACTERISTICS six characteristics is recommended for ther distinction to be made between
RECOMMENDED FOR THE diagnosis (see the Table): mild and moderate forms of malnutri-
DIAGNOSIS ADULT tion at this time.
MALNUTRITION insufcient energy intake The characteristics listed in the Table
In late 2009, the Academy appointed a (30-32); should be routinely assessed on admis-
Workgroup with A.S.P.E.N. representa- weight loss (33-36); sion and at frequent intervals through-
tion to identify and standardize markers loss of muscle mass (36,37); out the patients stay in an acute,
or characteristics that reect nutritional loss of subcutaneous fat chronic, or transitional care setting.
status vs the inammatory response that (36,37); Data obtained by clinicians should be
is associated with various diseases localized or generalized uid shared with all members of the health
and/or conditions. The group agreed that accumulation (36,37) that care team and should be considered in
732 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS May 2012 Volume 112 Number 5
FROM THE ACADEMY
the physicians formulation and docu- not always have access to the patients nutritional status may also shift as his
mentation of a diagnosis of malnutri- medical record and must rely on re- or her health status changes over time.
tion. The development of care plans for called or historical information pro- Therefore, assessment of malnourished
nutritional intervention and transi- vided by the patient, or others who ac- patients or of those at increased risk of
tional care on discharge should include company the patient, to assess malnutrition should be incorporated
monitoring of the characteristics at of- nutrition parameters such as caloric in- into the NCP or standard of care of the
ce or clinic visits following discharge. take and/or unintended weight loss. medical, nursing, and/or pharmacy
If malnutrition is suspected in pa- People with severe acute illness or professions.
tients seen in ambulatory care settings, severe trauma often experience ex-
the physician, ideally in concert with a treme metabolic stress. Although on
qualied nutrition professional, should admission they often present without INCORPORATION OF
assess the characteristics. A plan to ad- a prior history of malnutrition, the ASSESSMENT OF THE
dress observed nutrition decits should presence of the massive inammatory RECOMMENDED
be developed, implemented, and the response seen in such conditions limits CHARACTERISTICS INTO
characteristics monitored at frequent the effectiveness of nutrition interven- CLINICAL CARE
intervals followed by plan revision un- tions and can contribute to the rapid Incorporation of the assessment and
til nutritional status is optimized. development of malnutrition (8,9,43). documentation of the characteristics
The characteristics that have been Periods of interrupted feeding, im- into standard clinical practice is high-
identied are parameters that many posed to accommodate the variety of lighted below (see Sidebar):
practitioners already measure as part of medical-surgical interventions needed
the nutrition care (NCP) or nutrition as- History and Clinical Diagno-
to stabilize these patients, also contrib-
sessment process. They are not meant sis (3,7,13,32)
ute to the development of malnutrition
to replace all aspects of the NCP but are X The chief complaint and
despite the clinicians best efforts to
to be used to standardize the clinicians past medical history can
provide adequate calories and other
approach to the diagnosis and docu- be helpful in raising sus-
nutrients. The resultant malnutrition
mentation of the presence or absence of picion for increased risk
often blunts the effectiveness of medi-
adult malnutrition. of malnutrition and the
cal therapies prescribed and, thus, a vi- presence or absence of
cious cycle ensues (7-9,43). Therefore, inammation (Figure).
CONSIDERATIONS IN THE essentially on admission, many criti- Physical Exam/Clinical Signs
APPLICATION OF THE cally ill patients, especially elderly pa- (3,7-9,29)
CHARACTERISTICS IN CLINICAL tients, already are, or may be at signi- X Physical examination can
SETTINGS cant risk of developing malnutrition reveal the presence of
Each of the characteristics used in the di- and its related complications, even several of the diagnostic
agnosis of malnutrition may sometimes though the recommended characteris- characteristics of malnu-
be seen in patients for whom malnutri- tics for diagnosis of malnutrition may trition, such as weight
tion is not necessarily an appropriate di- be difcult to discern early in the hos- loss or gain, uid reten-
agnosis eg, the 80- to 90-year-old pa- pital course. As such, inability to eatie, tion, loss of muscle or fat,
tient who habitually consumes less than compromised intake immediately prior and other signs of specic
recommended calories, maintains a sta- to admission, repeated/extended ces- macro- and/or micronu-
ble, lower-than-recommended body sation of feeding regimens (long peri- trient deciencies.
weight, but is healthy and able to func- ods spent nil per os), frequent interrup- X Clinical signs of inam-
tion well in his or her home/commu- tions in oral/enteral nutrition therapies mation may be revealed,
nity environment; the weight loss ex- and unintended weight changemay including fever or hypo-
perienced by spinal cord injury be parameters of particular signicance thermia as well as other
patients, or those with various forms of for people in this category. Frequent, nonspecic signs of sys-
muscular dystrophy secondary to dein- intensive monitoring of the critically ill temic inammatory re-
nervation and disuse but who are con- patient to determine the actual level of sponse (eg, tachycardia,
suming adequate nutrients. Also prob- nutrients provided is needed to ensure hyperglycemia) that may
lematic is the patient who is, or who in that patient needs are appropriately facilitate an etiologically
a matter of a few days may become, se- addressed (43). based diagnosis (Figure).
verely malnourished, despite our best When developing a differential diag- Anthropometric Data (33-
efforts, but in whom the criteria to di- nosis of malnutrition, the clinician 36)
agnose malnutrition may be difcult to should also recognize that the degree of X Unintended weight loss
documentie, the young to middle- inammatory response that a patient is a well-validated indi-
aged adult who is acutely, critically ill may experience during the course of an cator of malnutrition.
or who has suffered major trauma. illness or condition often changes as the Weight should be mea-
Individuals who are ill, or in pain, are acuity level of the illness or condition sured on admission to
not always able to provide coherent an- changes (acute vs chronic or as new any clinical setting and
swers to questions asked by health care conditions or complications are super- monitored frequently
professionals. In acute and/or other imposed upon the patients current throughout the length of
health care settings, the clinician may state). The acuity level of the patients stay.
May 2012 Volume 112 Number 5 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 733
734
Malnutrition in the Context of Acute Illness or Malnutrition in the Context of Chronic Malnutrition in the Context of Social or
Injury Illness Environmental Circumstances
(1) Energy intake (reference 30) 75% of 50% of estimated 75% of 75% of 75% of 50% of estimated
estimated energy estimated estimated estimated energy
energy requirement for energy energy energy requirement for
requirement for 5 days requirement for requirement for requirement for 1 month
7 days 1 month 1 month 3 months
Malnutrition is the result of inadequate
food and nutrient intake or
assimilation; thus, recent intake
compared to estimated
requirements is a primary criterion
dening malnutrition. The clinician
may obtain or review the food and
nutrition history, estimate optimum
energy needs, compare them with
estimates of energy consumed and
report inadequate intake as a
percentage of estimated energy
requirements over time.
(2) Interpretation of weight loss % Time % Time % Time % Time % Time % Time
(references 33-36)
The clinician may evaluate weight in 1-2 1 wk 2 1 wk 5 1 mo 5 1 mo 5 1 mo 5 1 mo
light of other clinical ndings 5 1 mo 5 1 mo 7.5 3 mo 7.5 3 mo 7.5 3 mo 7.5 3 mo
including the presence of under- or
over- hydration. The clinician may 7.5 3 mos 7.5 3 mos 10 6 mo 10 6 mo 10 6 mo 10 6 mo
assess weight change over time
20 1y 20 1y 20 1y 20 1y
reported as a percentage of weight
lost from baseline.
Physical ndings (references 36,37)
Malnutrition typically results in
changes to the physical exam. The
clinician may perform a physical
exam and document any one of the
physical exam ndings below as an
May 2012 Volume 112 Number 5
indicator of malnutrition.
(3) Body fat Mild Moderate Mild Severe Mild Severe
Loss of subcutaneous fat (eg, orbital,
triceps, fat overlying the ribs).
Malnutrition in the Context of Acute Illness or Malnutrition in the Context of Chronic Malnutrition in the Context of Social or
Injury Illness Environmental Circumstances
a
A minimum of two of the six characteristics above is recommended for diagnosis of either severe or non-severe malnutrition. Height and weight should be measured rather than estimated to determine body mass index. Usual weight should be obtained
in order to determine the percentage and to interpret the signicance of weight loss. Basic indicators of nutritional status such as body weight, weight change, and appetite may substantively improve with refeeding in the absence of inammation.
Refeeding and/or nutrition support may stabilize but not signicantly improve nutrition parameters in the presence of inammation. The National Center for Health Statistics denes chronic as a disease/condition lasting 3 months or longer (reference
12). Serum proteins such as albumin and prealbumin are not included as dening characteristics of malnutrition because recent evidence analysis shows that serum levels of these proteins do not change in response to changes in nutrient intake
(references (22,23,52,53).
b
This table was developed by Annalynn Skipper PhD, RD, FADA. The content was developed by an Academy workgroup composed of Jane White PhD, RD, FADA, LDN, Chair; Maree Ferguson MBA, PhD, RD; Sherri Jones MS, MBA, RD, LDN; Ainsley Malone,
736 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS May 2012 Volume 112 Number 5
FROM THE ACADEMY
sessment of the relevance of character- tional and discharge planning protocols 10. Centers for Medicare & Medicaid Services.
must be developed to provide the re- Acute Inpatient Prospective Payment Sys-
istics used in malnutritions diagnosis
tem, DRG resources. http://www.cms.
and the routine documentation of mal- sources needed to successfully maintain hhs.gov/AcuteInpatientPPS/. Accessed
nutritions negative impact on health and nourish patients upon return to their March 29, 2012.
outcomes must also occur. The Acad- communities and should help to reduce 11. Jensen GL. Inammation as the key inter-
emy and A.S.P.E.N. are working to de- hospital readmission rates. face of the medical and nutrition univers-
es: A proactive examination of the future
velop a registry for this purpose. A re- of clinical nutrition and medicine. JPEN J
cent study by Fry and colleagues (51) SUMMARY Parenter Enteral Nutr. 2006;30(5):453-
showed that preexisting malnutrition 463.
The Characteristics Recommended to
and/or weight loss was a positive pre- Diagnose Malnutrition is a dynamic 12. Hagan JC. Acute and chronic diseases. In:
Mulner RM, ed. Encyclopedia of Health Ser-
dictive variable for all eight major sur- work in progress. Clinicians should ex- vices Research. Vol 1. Thousand Oaks, CA:
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cusable outcomes in a health care mended characteristics used to identify 13. Mueller C, Compher C, Druyan ME the
setting), with odds ratios ranging from and document malnutrition based American Society for Parenteral and
2.8 for postoperative pneumonia to Enteral Nutrition (A.S.P.E.N.) Board of Di-
upon an accumulation of evidence as rectors. A.S.P.E.N. Clinical Guidelines.
16.4 for intravascular device infection. data on their use is systematically col- Nutrition screening, assessment, and in-
The widespread, standardized collec- lected, analyzed, and disseminated. Pe- tervention. JPEN J Parenter Enteral Nutr.
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will ensure that the health and well be-
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AUTHOR INFORMATION
Authors: Jane V. White, PhD, RD, FADA (University of Tennessee, Knoxville); Peggi Guenter, PhD, RN (A.S.P.E.N., Havertown, PA); Gordon Jensen,
MD, PhD, FASPEN (The Pennsylvania State University, University Park); Ainsley Malone, MS, RD, CNSC (Mt Carmel West Hospital, Columbus, OH);
Marsha Schoeld, MS, RD (Academy of Nutrition and Dietetics, Chicago, IL); the Academy Malnutrition Work Group; the A.S.P.E.N. Malnutrition
Task Force; and the A.S.P.E.N. Board of Directors.
The authors would like to acknowledge the following individuals for their efforts in the development of the Characteristics and Markers tool.
The Academy Malnutrition Work Group: Maree Ferguson, MBA, PhD, RD; Sherri Jones, MS, MBA, RD, LDN; Louise Merriman, MS, CDN, RD; Pam
Michael, MBA, RD; Marsha Schoeld, MS, RD, LD; Terese Scollard MBA, RD, LD; Annalynn Skipper, PhD, FADA, RD; Jane V. White, PhD, RD, FADA;
and the A.S.P.E.N. Malnutrition Task Force members: Rose Ann Dimaria-Ghalili, PhD, RN; Peggi Guenter, PhD, RN, CNSN; Gordon Jensen, MD,
PhD, FASPEN; Ainsley Malone, RD, CNSC; Nilesh Mehta, MD, DCH; Steve Plogsted, PharmD, RPh, BCNSP; Annalynn Skipper, PhD, RD, FADA;
Jennifer Wooley, MS, RD, CNSD
738 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS May 2012 Volume 112 Number 5