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INTRODUCTION

Malnutrition occurs in 30–50% of hospitalized patients depending on the setting and criteria that are used. Poor wound healing, compromised immune status, impaired organ function, increased length of hospital stay, and increased mortality are among the notable adverse outcomes associated with malnutrition. It is now widely appreciated that acute or chronic inflammation contribute to the pathophysiology of disease-related or injury-related malnutrition. The presence of inflammation can also render historic nutrition assessment indicators, like albumin and prealbumin, unreliable, and inflammation diminishes favorable responses to nutrition therapies. In order to guide appropriate care, it is necessary to properly assess and diagnose malnutrition. Nutrition assessment is a comprehensive evaluation to diagnose a malnutrition syndrome and to guide intervention and expected outcomes. Patients are often targeted for assessment after being identified at nutritional risk based on screening procedures conducted by nursing or nutrition personnel within 24 h of hospital admission. Screening tends to focus explicitly on a few risk variables like weight loss, compromised dietary intake, and high-risk medical/surgical diagnoses. Preferably, health professionals complement this screening with a systematic approach to comprehensive nutrition assessment that incorporates an appreciation for the contributions of inflammation that serve as the basis for new approaches to the diagnosis and management of malnutrition syndromes.

MALNUTRITION SYNDROMES

Famine and starvation have long been leading causes of malnutrition and remain so in developing countries. However, with improvements in agriculture, education, public health, health care, and living standards, malnutrition in the settings of disease, surgery, and injury has become a prevalent concern throughout the world. Malnutrition now encompasses the full continuum of undernutrition and overnutrition (obesity). For the objectives of this chapter, we will focus upon the former. Historic definitions for malnutrition syndromes are problematic in their use of diagnostic criteria that suffer poor sensitivity, sensitivity, and interobserver reliability. Definitions overlap, and confusion and misdiagnosis are frequent. In addition, some approaches do not recognize undernutrition in obese persons. While the historic syndromes of marasmus, kwashiorkor, and protein-calorie malnutrition remain in use, this chapter will instead highlight evolving insights to the diagnosis of malnutrition syndromes.

The Subjective Global Assessment, a comprehensive nutrition assessment that included a metabolic stress of disease component, was described and validated in the 1980s. In 2010, an International Consensus Guideline Committee incorporated a new appreciation for the role of inflammatory response into their proposed nomenclature for nutrition diagnosis in adults in the clinical practice setting. Starvation-associated malnutrition is when there is chronic starvation without inflammation, chronic disease–associated malnutrition is when inflammation is chronic and of mild to moderate degree, and acute disease– or injury-associated malnutrition is when inflammation is acute and of severe degree (see Table 334-1 for examples). In 2012, the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (ASPEN) extended this approach using clinical characteristics to support diagnosis, including the presence of illness or injury, poor food intake, weight loss, and ...

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