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Assessing Indicators of Acute and Chronic Malnutrition
TUESDAY, OCTOBER 9
Research & Practice Innovations: Implementation of Nutrition Care Process and Health Outcome Measures Assessing Indicators of Acute and Chronic Malnutrition
Clinical Reliability and Validity of Nutrition Diagnoses
Author(s): A. Kinsella, A. Andrews, S. Peterson, O. Lateef, D. Sowa; Rush Univ. Med. Ctr., Chicago, IL
Author(s): E. B. Enrione,1 D. Reed,2 E. F. Myers3; 1Department of Dietetics & Nutrition, Florida Intl. Univ., Miami, FL, 2Cecil G. Sheps Center for Health Services Research, Univ. of North Carolina, Chapel Hill, NC, 3Research & Strategic Business Development, Academy of Nutrition and Dietetics, Chicago, IL
Learning Outcome: The learning outcome of this abstract is to identify indicators useful for differentiating between acute and chronic malnutrition. Introduction: The Academy of Nutrition and Dietetics/American Society Parenteral Enteral Nutrition Malnutrition workgroup recommend an etiology-based terminology including chronic and acute disease-related malnutrition; the objective of this project was to determine indicators for each. Methods: A convenience sample of 800 patients was utilized. Weight-malnutrition was defined as BMI below 18.5 or significant weight loss. Subjective global assessment (SGA) was performed; SGA-malnutrition was defined as mild/moderate/severe malnutrition. White blood cell count, temperature, pulse and respiratory rate were collected to determine inflammation/systemic inflammatory response syndrome (SIRS) within 48 hours of admission. Logistic regression determined best predictors of malnutrition and Chi-square analysis compared malnutrition with SIRS and functional status. Results: Prevalence of weight-malnutrition and SGA-malnutrition was 27% and 32%, respectively. Handgrip strength and functional status were predictors of SGA-malnutrition (p⬍0.01); while handgrip strength and SIRS were predictors of weight-malnutrition (p⬍0.01). Both weight- and SGA-malnutrition were associated with decreased functional status (p⬍0.01 for both) and low handgrip strength (⬍15) (p⬍0.01 for both). SIRS criteria alone was not associated with weight-(p⫽0.06) or SGA-malnutrition (p⫽0.18). Conclusion: Malnutrition is associated with decreased functional status and SIRS. More research is needed to define chronic versus acute malnutrition. Acute malnutrition may result from sudden onset of critical illness and be best characterized by weight loss and inflammation. Alternatively, chronic malnutrition is linked with both decreases in fat/muscle mass and functional status due to prolonged disease. SGA may be an appropriate indicator due to its inclusion of physical/functional findings; more information is needed to verify these associations.
Learning Outcome: Assess the reliability and validity of the nutrition diagnoses in clinical practice. Clinical studies that establish the reliability and validity with which Registered Dietitians (RDs) identify the nutrition diagnoses are needed to ascertain their accuracy. These studies have yet to occur. Therefore the purpose of this study was to determine the reliability and validity of the diagnoses, etiologies and signs/symptoms. Nine pairs of RDs randomly selected adult patients to diagnose. The two RDs in each pair independently assessed nutritional data from the same patient then each selected one nutrition diagnosis and rated the presence or absence of the etiologies and signs/symptoms. Clinical reliability was determined with percentage of agreement, kappa coefficient, and ppos and pneg. Clinical validity was calculated according to a clinical diagnostic validity (CDV) score. RDs practiced either in an acute-care facility (n⫽10, 55.6%), ambulatory/outpatient facility (n⫽4, 22.2 %) or both (n⫽4, 22.2%). Nutritional diagnoses were selected for 316 patients. Two raters selected the same diagnosis for 121 patients (38% agreement). Agreement was moderate (Kappa ⫽ 0.54) for etiologies and at the lower end of substantial (Kappa ⫽ 0.63) for signs/symptoms. For etiologies ppos⫽0.71 and pneg⫽0.78 and signs/ symptoms ppos⫽0.82 and pneg⫽0.79, indicating that the raters agreed on the presence of each as well as the absence. The overall CDV value for etiologies was .33 and for signs/symptoms was .44 indicating they were non-characteristic of the diagnoses. Although RDs knew a nutritional problem was present, they were in poor agreement as to the diagnosis, etiologies and signs/symptoms. An education protocol involving diagnosing and clinical reasoning for RDs and educators is warranted.
Funding Disclosure: None
Funding Disclosure: American Dietetic Association (Academy of Nutrition and Dietetics)
Collaborative Training with Medical and Dietetic Students in a Community Healthcare Setting
Specialized Bariatric RD Counseling Improves Pre-Surgery Weight Loss and Post-Surgical Excess Weight Loss
Author(s): J. L. Mincher, S. M. Leson; Human Ecology, Youngstown State University, Youngstown, OH
Author(s): J. M. Parrott,1 J. S. Parrott,2 O. Sowemimo,1 A. Adeyeri1; 1Central Jersey Bariatrics, Morganville, NJ, 2Dept of Nutritional Sciences, Dept of Quantitative Methods, Univ. of Med. and Dentistry of New Jersey, Newark, NJ
Learning Outcome: At the conclusion of the presentation the participant will be able to identify two methods for incorporating interdisciplinary collaborative training for dietetic students. In 2010 and 2011 the Academy of Nutrition and Dietetics House of Delegates (AND-HOD) discussed healthcare reform and interdisciplinary teams. It is especially significant at this time because of the creation of Patient Centered Medical Homes that the Registered Dietitian (RD) be included on the interdisciplinary team. The Patient Centered Medical Home is a new model of care at the primary care level that is accessible, family-centered, coordinated, comprehensive, and culturally effective (Robert Graham Center, 2007). The physician communicates directly with patients and their families integrating care with healthcare practitioners. The model focuses on wellness promotion and chronic disease management where patients are engaged and educated. A pilot project was conducted with students from Northeastern Ohio Medical University and senior dietetic students from Youngstown State University in cooperation with the Northeastern Ohio Health Education Center and the Youngstown Community Health Clinic. During the Community Nutrition supervised practice rotation the dietetic students (under the guidance of the RD) were assigned to a community health clinic and paired with the medical students at that clinic. Students participated in patient assessment, counseling, and medical team collaboration. At the conclusion of the rotation the students were surveyed regarding the collaborative experience. The medical students’ perception of the RD changed after their experience. The medical students’ indicated their awareness of the greater role the RD can provide in patient care. Both sets of students indicated a positive experience and the desire to continue to work together. Funding Disclosure: None
September 2012 Suppl 3—Abstracts Volume 112 Number 9
Learning Outcome: Participants will verbalize understanding of improvement in outcomes with specialized bariatric RD services. Background: Little is known about the benefits of utilizing the services of an RD specializing in bariatric surgery versus general nutrition education services. Methods: Medical records from 1129 bariatric surgery patients from a New Jersey surgical practice were examined. Association between 5% pre-surgery excess weight loss (PSEWL) and surgical procedure was examined using chi square paneled by type of nutrition services (specialist Registered Dietitian (RD) versus general nutrition education). Relation between specialized RD counseling and percent excess weight loss (EWL) at one, three, six, nine and 12 months was assessed using multiple regression after controlling for covariates. Results: Achievement of 5% PSEWL was significantly (X2⫽17.88, p⬍0.001) associated with surgical procedure, but only for generalized nutrition education, indicating lack of consistent nutrition education across procedures. After specialized RD services were instituted, an overall greater proportion of patients met the 5% PSEWL goal (66.9% versus 57.1%) and results were consistent across procedures (association between surgery type and attainment of 5% PSEWL was no longer significant). Use of specialized RD counseling was significantly associated with greater percent EWL at 1 and 3 months (F⫽34.56, p⬍0.001, R2⫽.08, ⫽.056 and F⫽123.34, p⬍0.001, R2⫽.40, ⫽.074 respectively). Conclusions: Implementation of specialized RD services was associated with greater attainment of 5% PSWL and greater consistency of nutrition counseling across surgical procedures compared to general nutritional education. Additionally, use of specialized RD services was associated with greater percent excess weight loss at one and three months after controlling for covariates. Funding Disclosure: None
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
A-69
Research & Practice Innovations: Implementation of Nutrition Care Process and Health Outcome Measures Assessing Indicators of Acute and Chronic Malnutrition
Clinical Reliability and Validity of Nutrition Diagnoses
Author(s): A. Kinsella, A. Andrews, S. Peterson, O. Lateef, D. Sowa; Rush Univ. Med. Ctr., Chicago, IL
Author(s): E. B. Enrione,1 D. Reed,2 E. F. Myers3; 1Department of Dietetics & Nutrition, Florida Intl. Univ., Miami, FL, 2Cecil G. Sheps Center for Health Services Research, Univ. of North Carolina, Chapel Hill, NC, 3Research & Strategic Business Development, Academy of Nutrition and Dietetics, Chicago, IL
Learning Outcome: The learning outcome of this abstract is to identify indicators useful for differentiating between acute and chronic malnutrition. Introduction: The Academy of Nutrition and Dietetics/American Society Parenteral Enteral Nutrition Malnutrition workgroup recommend an etiology-based terminology including chronic and acute disease-related malnutrition; the objective of this project was to determine indicators for each. Methods: A convenience sample of 800 patients was utilized. Weight-malnutrition was defined as BMI below 18.5 or significant weight loss. Subjective global assessment (SGA) was performed; SGA-malnutrition was defined as mild/moderate/severe malnutrition. White blood cell count, temperature, pulse and respiratory rate were collected to determine inflammation/systemic inflammatory response syndrome (SIRS) within 48 hours of admission. Logistic regression determined best predictors of malnutrition and Chi-square analysis compared malnutrition with SIRS and functional status. Results: Prevalence of weight-malnutrition and SGA-malnutrition was 27% and 32%, respectively. Handgrip strength and functional status were predictors of SGA-malnutrition (p⬍0.01); while handgrip strength and SIRS were predictors of weight-malnutrition (p⬍0.01). Both weight- and SGA-malnutrition were associated with decreased functional status (p⬍0.01 for both) and low handgrip strength (⬍15) (p⬍0.01 for both). SIRS criteria alone was not associated with weight-(p⫽0.06) or SGA-malnutrition (p⫽0.18). Conclusion: Malnutrition is associated with decreased functional status and SIRS. More research is needed to define chronic versus acute malnutrition. Acute malnutrition may result from sudden onset of critical illness and be best characterized by weight loss and inflammation. Alternatively, chronic malnutrition is linked with both decreases in fat/muscle mass and functional status due to prolonged disease. SGA may be an appropriate indicator due to its inclusion of physical/functional findings; more information is needed to verify these associations.
Learning Outcome: Assess the reliability and validity of the nutrition diagnoses in clinical practice. Clinical studies that establish the reliability and validity with which Registered Dietitians (RDs) identify the nutrition diagnoses are needed to ascertain their accuracy. These studies have yet to occur. Therefore the purpose of this study was to determine the reliability and validity of the diagnoses, etiologies and signs/symptoms. Nine pairs of RDs randomly selected adult patients to diagnose. The two RDs in each pair independently assessed nutritional data from the same patient then each selected one nutrition diagnosis and rated the presence or absence of the etiologies and signs/symptoms. Clinical reliability was determined with percentage of agreement, kappa coefficient, and ppos and pneg. Clinical validity was calculated according to a clinical diagnostic validity (CDV) score. RDs practiced either in an acute-care facility (n⫽10, 55.6%), ambulatory/outpatient facility (n⫽4, 22.2 %) or both (n⫽4, 22.2%). Nutritional diagnoses were selected for 316 patients. Two raters selected the same diagnosis for 121 patients (38% agreement). Agreement was moderate (Kappa ⫽ 0.54) for etiologies and at the lower end of substantial (Kappa ⫽ 0.63) for signs/symptoms. For etiologies ppos⫽0.71 and pneg⫽0.78 and signs/ symptoms ppos⫽0.82 and pneg⫽0.79, indicating that the raters agreed on the presence of each as well as the absence. The overall CDV value for etiologies was .33 and for signs/symptoms was .44 indicating they were non-characteristic of the diagnoses. Although RDs knew a nutritional problem was present, they were in poor agreement as to the diagnosis, etiologies and signs/symptoms. An education protocol involving diagnosing and clinical reasoning for RDs and educators is warranted.
Funding Disclosure: None
Funding Disclosure: American Dietetic Association (Academy of Nutrition and Dietetics)
Collaborative Training with Medical and Dietetic Students in a Community Healthcare Setting
Specialized Bariatric RD Counseling Improves Pre-Surgery Weight Loss and Post-Surgical Excess Weight Loss
Author(s): J. L. Mincher, S. M. Leson; Human Ecology, Youngstown State University, Youngstown, OH
Author(s): J. M. Parrott,1 J. S. Parrott,2 O. Sowemimo,1 A. Adeyeri1; 1Central Jersey Bariatrics, Morganville, NJ, 2Dept of Nutritional Sciences, Dept of Quantitative Methods, Univ. of Med. and Dentistry of New Jersey, Newark, NJ
Learning Outcome: At the conclusion of the presentation the participant will be able to identify two methods for incorporating interdisciplinary collaborative training for dietetic students. In 2010 and 2011 the Academy of Nutrition and Dietetics House of Delegates (AND-HOD) discussed healthcare reform and interdisciplinary teams. It is especially significant at this time because of the creation of Patient Centered Medical Homes that the Registered Dietitian (RD) be included on the interdisciplinary team. The Patient Centered Medical Home is a new model of care at the primary care level that is accessible, family-centered, coordinated, comprehensive, and culturally effective (Robert Graham Center, 2007). The physician communicates directly with patients and their families integrating care with healthcare practitioners. The model focuses on wellness promotion and chronic disease management where patients are engaged and educated. A pilot project was conducted with students from Northeastern Ohio Medical University and senior dietetic students from Youngstown State University in cooperation with the Northeastern Ohio Health Education Center and the Youngstown Community Health Clinic. During the Community Nutrition supervised practice rotation the dietetic students (under the guidance of the RD) were assigned to a community health clinic and paired with the medical students at that clinic. Students participated in patient assessment, counseling, and medical team collaboration. At the conclusion of the rotation the students were surveyed regarding the collaborative experience. The medical students’ perception of the RD changed after their experience. The medical students’ indicated their awareness of the greater role the RD can provide in patient care. Both sets of students indicated a positive experience and the desire to continue to work together. Funding Disclosure: None
September 2012 Suppl 3—Abstracts Volume 112 Number 9
Learning Outcome: Participants will verbalize understanding of improvement in outcomes with specialized bariatric RD services. Background: Little is known about the benefits of utilizing the services of an RD specializing in bariatric surgery versus general nutrition education services. Methods: Medical records from 1129 bariatric surgery patients from a New Jersey surgical practice were examined. Association between 5% pre-surgery excess weight loss (PSEWL) and surgical procedure was examined using chi square paneled by type of nutrition services (specialist Registered Dietitian (RD) versus general nutrition education). Relation between specialized RD counseling and percent excess weight loss (EWL) at one, three, six, nine and 12 months was assessed using multiple regression after controlling for covariates. Results: Achievement of 5% PSEWL was significantly (X2⫽17.88, p⬍0.001) associated with surgical procedure, but only for generalized nutrition education, indicating lack of consistent nutrition education across procedures. After specialized RD services were instituted, an overall greater proportion of patients met the 5% PSEWL goal (66.9% versus 57.1%) and results were consistent across procedures (association between surgery type and attainment of 5% PSEWL was no longer significant). Use of specialized RD counseling was significantly associated with greater percent EWL at 1 and 3 months (F⫽34.56, p⬍0.001, R2⫽.08, ⫽.056 and F⫽123.34, p⬍0.001, R2⫽.40, ⫽.074 respectively). Conclusions: Implementation of specialized RD services was associated with greater attainment of 5% PSWL and greater consistency of nutrition counseling across surgical procedures compared to general nutritional education. Additionally, use of specialized RD services was associated with greater percent excess weight loss at one and three months after controlling for covariates. Funding Disclosure: None
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
A-69