STRENGTH

AMBASSADOR
Shifting Paradigm in Patient
Care

Low lean mass across the continuum of care

 Outline

GI problems Recent criteria

Impact of low /
and low lean lean mass recommendation
mass
• BEYOND BMI
 Malnutrition in Hospital

30 – 50 % were 1/3 well- Weight loss +

malnourished at nourished loss of muscle
admission1 patients at mass increased
admission  26%
became READMISSION
undernourished risk4.5
during
hospitalization 2,3

1. Sriram K, Sulo S et al, J Parenter Enteral Nutr 2017;41: 384

2. Braunschweigh et al, J Am Diet Assoc 2000; 100(11): 1316-1322
3. Tappenden, J Acad Nutr Diet 2013; 113: 1219-1237
4. Gariballa S, Elessa A Clinical Nutrition 2013
5. Allaudeen N et al. J Hosp Med 2011; 6: 54
 • Difficulty swallowing
GI • GI symptoms: constipation,
proble thirst, nausea
ms • Changing nutritional
requirements (protein intake)

Disease • Restrictive therapeutic diets

Contribut s and • Drugs and polypharmacy
(decrease appetite)
e to pain • Undiagnosed, untreated pain
undernutri
tion Unhealt
hy • Food preferences (limited)
• Physical inactivity (lead to
behavio muscle loss)
urs

Pulisetty S, et al. In: Morley JE, Thomas DR, eds. Geriatric Nutrition:
CRC Press; 2007:1-9.
 Malnutriti
on: Increased Increased
negatively medical care
cost
need for
drugs

impacted
to
Increased Increased risk
length of of admission

outcomes
hospital stay to hospital

and cost
Naberhuis JK, et al. Nutrition and Dietary
Supplements 2017:9 55–62
Malnutrition + nutritional deficiencies : cost of
care in BPJS

October 29, 2019 Enter title via "insert>header and footer>footer" | 7

 To screen

Is BMI a reliable tool?

malnutrition:

Age 75 31
Weight 56 56
Height 132
157
BMI 32.1
22.7

Vandewoude, M.F. Personal communication, 2014.

8
Most people associate muscles with
movement, structure, and physical
strength.

• But muscles
also perform
important
metabolic
functions. 1
0
 One of the key metabolic
functions of muscle is providing an
alternative source of energy.

Muscles Store
Key Sources of
Energy

Amino acids are the

Glucose is the body’s Amin building blocks of
Gluc protein and an
primary source of o
ose energy. Acids alternate source for
glucose/energy
production.

• 1. Argilés HM, et al. JAMDA. 2016;17:789-796. 2. Xi P, et al. Frontiers in Bioscience. 2011;16:578-597.

1
1
 When this imbalance or metabolic stress
happens,
muscles play a critical role in helping to balance
metabolic
The body needs
compensates by breaking. down
muscle for
extra energy and other needs — part of the
catabolic response.

Nutrition
al Intake Energy Storag
+
Needs e

Muscles Store
Key Sources of
Energy

Amino
Glucose
Acids

• 1. Argilés HM, et al. JAMDA. 2016;17:789-796. 2. Xi P, et al. Frontiers in Bioscience. 2011;16:578-597. 3.

1
Demling RH. ePlasty. 2009;9:65-94. 4. Wolfe RR. Am J Clin Nutr. 2006;84:475-82. 2
 Please
Lower lean
mass in add
undernourishe local
d patients BIA RESULTS IN PATIENTS WITH GI
studies
with GI
problems
PROBLEMS AND LIVER
DISEASES IN RSCM, JUN – DEC 2013
well nourished Undernourished

49.6

39.7

32.2

25.2

6.2

3.5
p< p= p<
0.001 0.003 0.001
LEAN MASS (KG) BODY CELL MASS PHASE ANGLE
(KG)

Cross-sectional, retrospective study in 56 hospitalized patients in internal Medicine Ward RSCM period of Jun-
Dec2013, following SGA and body composition measurement using Bioelectric Impedance Analysis.
Taufiq and Ari Fahrial et al. Journal Penyakit Dalam Indonesia 2014 ; 1(2): 108 - 113
Low lean
mass and
health
outcome
s
 Odd
ratio for
post-
operativ
e
complica
tion
 KRITERIA malnutrition:
Global Leadership Initiative on Malnutrition
(GLIM)
Malnutrition Criteria
Phenotypic criteria : Etiologic criteria:
Reduced muscle mass Reduced intake
Low BMI Diseases or inflammation
Weight loss (un
intentionally)

To diagnose malnutrition at least 1 phenotypic criterion and 1 etiologic

criterion should be present

*GLIM : gabungan perwakilan dari ASPEN (American Society for Parenteral and Enteral Nutrition), ESPEN (European Society for
Clinical Nutrition and Metabolism), FELANPE (Federacion Latinoamericana de Terapia Nutricional, Nutricion Clinica y
Metabolismo) dan PENSA (Parenteral and Enteral Nutrition Society of Asia).
Cederholm T, et al. Clin Nutr. 2019; 38 : 1 = 9
 Principles of advancing patient
care
Create institutional culture Fact: nutrition improved
patient outcomes
Redefine roles to include Nutrition support team, physician
nutrition
leadership
Recognize and diagnose all Use valid screening tool
patients at risk Include malnutrition
characteristics in MR
Implement prompt intervention
+ continue monitoring

Communicate nutrition care plan

Discharge nutrition
care + education plan
Tappenden, 2013
Take home messages
Low lean mass occurs at any BMI: a “NEW FACE” of
Malnutrition

Low lean mass negatively impacted to clinical

outcomes and healthcare cost

All patients are at risk of malnutrition

• Loss Appetite, reduce lean mass

(weight loss)