of the concurrent medical condition for a nutrition diagnosis of malnutrition. Te benchmarks for each characteristic are further delineated by severity (i.e., non-severe or undernutrition and severe malnutrition).13

Te table below outlines the six characteristics of malnutrition used to identify nutrition risk.

Characteristics of Adult Malnutrition in ACUTE ILLNESS OR INJURY13

Non-Severe Malnutrition or Undernutrition

Insufficient energy intake < 75% of estimated needs for longer than seven days

Interpretation of weight loss • 1% to 2% weight loss in one week

• 5% weight loss in one month

• 7.5% weight loss in three months

Changes in body composition: mild loss of body fat

Changes in body composition: mild loss of muscle mass

Changes in body composition: mild accumulation of fluid

Not applicable

3 4

5 6

1 2 Severe Malnutrition

Insufficient energy intake < 50% of estimated needs for longer than seven days

Interpretation of weight loss • > 2% weight loss in one week

• > 5% weight loss in one month

• > 7.5% weight loss in three months

Changes in body composition: moderate loss of body fat

Changes in body composition: moderate loss of muscle mass

Changes in body compo- sition: moderate to severe accumulation of fluid

Markedly reduced grip strength

To implement the consensus guidelines, the first step is to iden-

tify nutrition risk indicators for undernutrition or malnutrition. It is important to note that the Malnutrition Task Force did not include laboratory test results as nutrition risk indicators for malnutrition due to lack of sensitivity of tests such as albumin and prealbumin to predict changes in nutrition status. Next, the RDN or interprofessional team member determines

the context in which these risk indicators have presented based on the degree of inflammation present. Acute injury, surgery or infection are associated with marked inflammatory stress. Chronic conditions (defined as lasting for three months or longer) are asso- ciated with mild to moderate inflammatory stress. Inflammation is not a factor in malnutrition in the context of environmental circumstances (e.g., starvation). Why are there no laboratory test results included in the con-

sensus guidelines? Historically, lab test results for albumin and prealbumin have been used as markers of malnutrition and pre- dictors of improved nutrition status. However, using the current standards for evidenced-based medicine, there is insufficient evidenced-based research on the sensitivity of serum albumin and prealbumin levels as markers of nutrition status. Albumin is the primary serum protein synthesized by the liver

and serves to maintain colloidal osmotic or oncotic pressure. Colloidal osmotic or oncotic pressure is a measurement of pressure exerted within the cardiovascular system by proteins found in blood plasma. Proteins like albumin are relatively large molecules and do not readily pass through the cell membrane. Maintaining

24 Visit us at • 2016

an adequate pressure is essential for fluid homeostasis, preventing movement of fluid into interstitial spaces. Te serum albumin level is not a sensitive measure of changes

in nutritional status because of its long half-life (up to 21 days) and large extravascular reserves. When serum levels fall, albumin moves from the extravascular compartment to the serum. When the synthesis of albumin increases, albumin moves from the serum to the extravascular reserves. Levels of albumin may remain within normal ranges or slightly below normal ranges during uncomplicated starvation due to the redistribution of reserves.17-21 In the presence of inflammatory stress, levels of albumin and

prealbumin plummet since these are negative acute-phase reac- tants. Cytokine mediators redirect the liver to synthesize positive acute-phase reactants rather than negative acute-phase reactants. In 1948, Ancel Keys reported no significant difference in serum albumin levels of healthy males on a semistarvation diet for six months. Yet their percentage of body fat and BMI plummeted to ranges associated with underweight and malnutrition.22


findings support the observation that in the absence of acute or chronic inflammatory processes, serum albumin levels are not affected by significant changes in dietary intake and are not a useful marker of malnutrition. A more recent study examined changes in prealbumin, nutrient

intake and systemic inflammation in elderly recuperative care patients. Prealbumin, C-reactive protein, tumor necrosis factor, interleukin-6 and their soluble receptors were measured at admis- sion and discharge. Daily calorie counts were summarized as the percentage of estimated protein and energy nutrient requirements consumed. When the inflammatory marker levels and the protein intake data were compared with serum prealbumin level variance, it appeared that inflammatory substances were much more influential on the serum prealbumin levels than protein intake. In fact, protein intake accounted for only 6% variance in prealbumin, compared to 56% change associated with the inflammatory markers.23


findings suggest that serum prealbumin levels are not reflective of changes in nutrition status in recuperating patients and cannot substitute for a detailed nutritional assessment. Inflammatory biomarkers such as C-reactive protein, ferritin and

other positive acute-phase reactants rise precipitously with acute inflammation and wane as inflammation subsides. However, the literature is inconclusive on the relationship between the changes in these biomarkers and changes in nutrition status.18-23

For these

reasons, laboratory test results for albumin, prealbumin and other serum proteins were not included as characteristics of malnutrition.

Nutrition, inflammation, wound healing All wounds — whether intentional (e.g., surgical incisions) or unin-

tentional (e.g., pressure ulcers, vascular-related wounds or traumatic injuries) — trigger an inflammatory response. Inflammation may be due in part to infection, but it is always part of the healing cascade. Te inflammatory response requires energy and protein to synthe- size the products necessary for recovery: immune cells, cytokines, oxidants and positive acute-phase reactants. Te cytokines can have a negative influence on the patient’s nutritional status by trig- gering anorexia and fatigue. Patients are not hungry despite having increased energy and protein requirements. In addition, the body tends to use protein less efficiently, meaning that more amino acids

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