NUTRITION ASSESSMENT is the purview of the dietitian in a variety of settings working alongside physicians, nurses, pharmacists, and other health care professionals. The formal process of nutrition assessment for the purposes of systematically identifying malnutrition and risk of malnutrition began more than 4 decades ago. From the lessons learned in the past, now is the time to reset our course.
Assessment of nutritional status was part of a routine physical examination, promoted by Sandstead et al1 in 1969, for family physicians, internists, and pediatricians. But dietitians took notice too. There was a call to recognize the early signs of clinical and subclinical malnutrition gathered from food intake data, interviews, and notations in the medical record.2 The demand for action occurred in a 1974 article by Butterworth,3 "The Skeleton in the Hospital Closet." He alerted physicians, nurses, and dietitians to focus on using nutrition assessment techniques to evaluate patients for risk of malnutrition during the course of hospitalization. From this auspicious beginning, it has taken several decades of examining the appropriateness, sensitivity, specificity and parameters used.
GROWTH OF NUTRITION SUPPORT
Following the initial spate of articles, physicians and dietitians promulgated the use of rapid identification of malnutrition in a busy hospital environment. Efforts were hampered by findings of inadequate documentation of heights and weights, an average nil per os of 3.1 days, and one-third of patients with anemia and hypoalbuminemia.4 Although diagnostic and specialized therapies were well documented in medical records, simple nutrition diagnoses were not. Interest in classification and treatment of malnutrition intensified, and nutrition support teams were established as an approach to deal with the matter; use of hyperalimentation increased along with the collection of computer-assisted nutrition data. One survey in 1982 revealed that almost 30% of US hospitals had formal nutrition support services and those nutrition support services demonstrated better performance on achieving inpatient nutrition assessments.5
The sustainability of nutrition support teams was not viable in the long term, especially as technological advances and health care costs rose. Every dietitian was expected to be an assessor of nutritional status and nutrition assessment was important for more than detecting malnutrition.
The accuracy of nutrition assessments have defied clinicians over the decades since publication of "The Skeleton in the Hospital Closet."3 We have experienced the awareness phase in the 1970s and early 1980s, screening for all in the late 1980s (outpatient, inpatient, longterm care, community, etc), specialized nutrition support teams, and tool development for screening and comprehensive nutrition assessments throughout the 1990s. By 2000, several clinicians had the foresight to question and reevaluate what we do. How could we be most effective in identifying and defining malnutrition and providing the best care to our patients?
SCREENING FOR NUTRITIONAL RISK
Nutrition screening was not routinely included in medical exams. An era of screening for malnutrition was essential to clarify to evaluate nutritional status. Nutritional health was based on subjective measures, appetite and reported weight history, and quantifiable measures including anthropometric and biochemical data in the medical record. Screening was the key to classify patients for mild, moderate, or high risk of malnourishment.
Early screening procedures were transformed by trial and error. Screening for malnutrition risk originally focused on serum albumin, body weight, and food intake conducted by dietitians. To accumulate meaningful data, nurses, technicians, and other staff (plus dietetic students and volunteers) targeted pertinent information on a form designed by an organization/institution or from tools suggested in peer-review publications. The purpose of screening was to pursue those in greatest need for nutritional intervention or a comprehensive nutrition assessment and to institute treatment goals. However, one size does not fit all and dietitians in specialty units augmented forms or developed their own for their specific patient population. Later screening forms or questionnaires included a rating or number to identify "no risk," "potential risk," or "high risk."
Some instruments have been developed and tested for validity and reliability as shown in several recent articles, including Malnutrition Universal Screening Tool, Malnutrition Screening Tool for cancer patients, Nutrition Risk Screening, Mini-Nutritional Assessment, Short Nutrition Assessment, and SCREEN-II for the older adults living in the community.6-8 The common denominator has been weight loss in the instruments. For comparison purposes, the Subjective Global Assessment has often been the standard as described in this issue by Platek et al.8 Primarily used with surgical patients, Subjective Global Assessment is considered effective for assessment, not screening, and requires that practitioners have adequate time for collecting information and overseeing proper techniques.9 Recently, a patient-generated form has been correlated with length of hospital stays.7
By 2005, the Joint Commission on Accreditation of Healthcare Organizations required patient screening for detecting malnutrition within 24 hours of admission.10 The parameters for classifying malnutrition should remain simple, practical, and relevant to interventions. The objectives were to determine how to intervene in caring for patients and to improve the health and nutritional status of individual patients. Intervention has been hampered by diverse intervention methods and data collection, how decisions are made in a medical environment, and the complexity of nutrition and its effect on health and disease. The intervening years had criteria, but they could not be fully applied in routine hospital care. No one approach was universal to diagnose and document malnutrition in adults.
A PROMISING FUTURE
Forty years since the first wake-up call for conducting nutrition assessment in the hospital, 3 professional societies, American Society for Parenteral and Enteral Nutrition, European Society for Parenteral and Enteral Nutrition, and Academy of Nutrition and Dietetics (Academy), joined together to reexamine the criteria established over the years.11 They endorsed a new set of diagnostic criteria to classify adult malnutrition in clinical practice.
What is staying the same is the categorization of the mild, moderate, and severe malnutrition. What is different is the attention to hypermetabolic and inflammatory conditions that may contribute to poor response to nutrition intervention and increase morbidity and mortality. For the future, it is timely to test and monitor specific inflammatory markers for diagnosing malnutrition and clearly separate the value to institutions of appropriate screening, assessment, and coding for malnutrition.12 Added to the definition has been the inclusion of social and environmental circumstances and severity of illness (acute or chronic of >3 months).13 With an aging population, new challenges have emerged (feeding to support inflammation metabolism and recovery) and others will continue to emerge.
For more than 3 decades, one of the major biomarkers for malnutrition was serum albumin. From an evidence analysis by the Academy, it was concluded they are not consistent indicators of weight loss, calorie restrictions, or nitrogen balance and do not change.6 Serum albumin and other serum proteins are considered better indicators of the severity of inflammatory response, rather than a reflection of poor nutritional status.14 The review also indicated that only 3% of patients admitted to acute care were diagnosed as malnourished despite prevalence rates of malnutrition risk recorded at levels of 15% to 60% from the 1970s until today.6
A lot of hard work has advanced nutrition assessment in dietetic practice. The 2012 criteria offer another beginning for clinicians to characterize nutritional status and gauge its effect on the health and recovery from illness. Is assessment "within our reach" with new criteria or still a moving target with a need to balance standards, biophysical outcomes, individual needs, and disease states? It will take the collective focus and discerning minds of dietetic and nutrition practitioners to pursue another path to successful nutrition assessments for our patients. Simply finding early signs and symptoms of malnutrition will not be enough. We will need to identify how nutrition and health and disease are intertwined in distinguishing nutritional problems and affecting the outcomes of nutrition therapy.
This year Topics in Clinical Nutrition reflected on the past and current knowledge of nutrition screening and assessment applied to selected patient populations. These concerns still resonate with dietitians interested in proving the highest quality of nutritional care.
What should registered dietitian nutritionists do to maintain the tenets of effective "nutrition assessment"?
* Voraciously read the evidence for documenting malnutrition for their patients.
* Make a plan for improving clinical outcomes while reducing lengths of stay and health care costs in your own environment.
* Find a way to measure malnutrition for all segments of your patients.
* Document your successful interventions on an annual basis.
* Conduct your own pilot project on the effectiveness of the new diagnostic criteria and disseminate your findings.
* Lead a collaboration with physicians, nurse practitioners, and physician assistants for training the next generation of nutrition assessors.
* Decide on the best screening and assessment strategies and evolve your practices as the research changes.
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