THE GOAL OF THIS CONTINUING EDUCATION PRO- GRAM is to increase understanding of the trajectory of the undernutrition/malnutrition continuum and the impact of inflam- matory stress on the absorption and use of nutrients required for wound healing. After studying the material presented here, you will be able to:

1 2

3 • Explore the undernutrition/malnutrition continuum

• Examine the impact of inflammation on nutritional status and describe the role of nutrition in wound healing

• Describe the role of interprofessional collaboration in meeting nutrient requirements to promote wound healing

By Mary Litchford, PhD, RDN, LDN H

ippocrates observed that “healing is a matter of time, but sometimes also a matter of opportunity.” Are wound care clinicians missing a pivotal “opportunity” in the arena of

wound care? In Western healthcare, we invest billions of dollars in medications and products to promote healing of wounds, yet many interventions generate suboptimal results. Nutrition, customized to the patient’s requirements, offers an opportunity not only to prevent wounds from developing but to optimize wound healing as well.

Undernutrition/malnutrition continuum Many healthcare administrators may not be aware of the high

prevalence of malnutrition in their healthcare organization’s patient population. Many healthcare professionals would be surprised to learn that 40% to 60% of hospitalized older adults are malnourished or at risk for malnutrition, and between 40% and 85% of nursing home residents are malnourished. In fact, maintaining a body weight within or above the accepted healthy range does not always indicate a patient is not malnourished. Te general public may also be oblivious to declining nutrition status among friends and family. It is estimated that 20% to 60% of home care patients are malnourished.1

Most observers are taken aback when a seemingly

healthy adult becomes malnourished after a week in the hospital. Malnutrition is most often considered primarily a problem in the developing world due to famine, natural disaster or political unrest, not a health issue prevalent in Western societies. Malnutrition may be due to starvation, inflammation or a combination of both.2-3

Starvation-related malnutrition is due to

insufficient food intake and occurs insidiously over time. Starvation-Related Continuum


Eating more low-nutrient foods = suboptimal nutrient intake

Eating less or skipping meals = undernutrition, subclinical deficiencies Chronic disease + meds =

change in nutrient needs and inflammation Weight loss,

strength malnutrition, frailty Inflammation-related malnutrition evolves more rapidly as a

result of the inflammatory process. During acute illness, or even fol- lowing invasive procedures, the inflammatory process is activated, as it is essential for addressing the stressor and for the healing process.

Inflammation functions as a protective response of the body to injury, infections and physiological stress. It triggers an immune response to redirect the synthesis of immune cells, cytokines and acute phase reactants to address the physiological assault. Energy and protein are two of the essential substrates required to synthesize these new cells and molecules. Once the physiological assault is addressed and the clinical status begins to improve, the inflammatory response wanes. Short-term side effects of the inflammatory response can include anorexia and increased nutrient requirements. Te cascade of events that drives both starvation-related and inflammation-re- lated malnutrition ultimately results in depleted nutrient reserves, changes in body composition (muscle and fat wasting and fluid accumulation) and reduced strength.4

Inflammation-Related Continuum of UNDERNUTRITION to MALNUTRITION4

Adequate food intake + injury, surgery or acute illness =


Inflammation immune response nutrient needs mobilize body reserves

Response to injury, surgery or acute illness =

food intake loss,

Nutrient needs + food intake = weight strength

malnutrition and cachexia

Nutrition screening tools Every patient newly admitted to the hospital should be screened for

risk of malnutrition. Even overweight and obese patients may be mal- nourished and have muscle wasting. Patients at risk for malnutrition can be identified using a validated nutrition screening tool such as the Mini Nutrition Assessment,5-7 nutrition Universal Screening Tool,9-10

Malnutrition Screening Tool,8 Nutrition Risk Screening11

the Short Nutrition Assessment Questionnaire.12

as malnourished upon admission should be referred to the RDN for a comprehensive nutrition assessment including the age-appropriate characteristics of malnutrition.13-16

Mal- and

Patients identified Information gathered from the

nutrition screening tool should be used to complete the pressure ulcer risk assessment tool and other tools that have a nutrition subscore.

Markers of malnutrition Te International Guideline Committee, working with the American

Society for Enteral and Parenteral Nutrition and the Malnutrition Task Force from the Academy of Nutrition and Dietetics, published a standardized set of diagnostic characteristics to be used to identify and document different types of adult malnutrition.13

Te Consensus

Guidelines on Malnutrition identify diagnostic characteristics of malnutrition that reflect both the degree of inflammatory stress and the patient setting. A consensus statement by the Academy of Nutrition and Dietet-

ics and the American Society for Parenteral and Enteral Nutrition outlines criteria that are used to determine a nutrition diagnosis of malnutrition rather than a medical diagnosis of malnutrition. Tere are six characteristics of malnutrition that include sub- optimal energy intake, significant weight loss, changes in body composition (i.e., fat loss), muscle wasting and fluid accumulation, and changes in grip strength. For these, the clinician must iden- tify a minimum of two characteristics that relate to the context

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