How to spot malnutrition

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Over the last few weeks, we have been focusing on how to prevent and detect malnutrition in seniors. The signs of malnutrition in older adults can be tough to spot, especially in people who don’t seem at risk — but uncovering problems at the earliest stage can help prevent complications later. To detect malnutrition:

Observe your loved one’s eating habits. Spend time with your loved one during meals at home, not just on special occasions. If your loved one lives alone, find out who buys his or her food. If your loved one is in a hospital or long term care facility, visit during mealtimes.

Watch for weight loss. Help your loved one monitor his or her weight at home. You might also watch for other signs of weight loss, such as changes in how clothing fits.

Be alert to other red flags. In addition to weight loss, malnutrition can cause poor wound healing, easy bruising and dental difficulties.

Know your loved one’s medications. Many drugs affect appetite, digestion and nutrient absorption.

In the final excerpt of how to prevent and detect malnutrition in seniors we will discuss what steps you can take to help avoid malnutrition.

How Malnutrition Begins

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In our second installment on the serious health consequences of malnutrition in seniors focuses on how malnutrition begins. Information is courtesy of the Mayo Clinic staff writers

The causes of malnutrition might seem straightforward — too little food or a diet lacking in nutrients. In reality, though, malnutrition is often caused by a combination of physical, social and psychological issues. For example:

Health concerns. Older adults often have health problems, such as dementia or dental issues that can lead to decreased appetite or trouble eating. Other factors that might play a role include a chronic illness, use of certain medications, difficulty swallowing or absorbing nutrients, a recent hospitalization, or a diminished sense of taste or smell.

Restricted diets. Dietary restrictions — such as limits on salt, fat, protein or sugar — can help manage certain medical conditions, but might also contribute to inadequate eating.

Limited income. Some older adults might have trouble affording groceries, especially if they’re taking expensive medications.

Reduced social contact. Older adults who eat alone might not enjoy meals as before, causing them to lose interest in cooking and eating.

Depression. Grief, loneliness, failing health, lack of mobility and other factors might contribute to depression — causing loss of appetite.

Alcoholism. Too much alcohol can interfere with the digestion and absorption of nutrients. Nutrients might also be lacking if alcohol is substituted for meals.

Be alert of the early triggers and warning signs of malnutrition to prevent the onset of malnutrition before it begins.  The next blog in our series will focus on how to spot malnutrition in seniors.

Senior health: How to prevent and detect malnutrition

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Over the next several weeks we will be sharing information from the Mayo Clinic staff writers on the importance of nutrition for seniors.  Specifically, we will focus on malnutrition and the serious health consequences.

Good nutrition is critical to overall health and well-being — yet many older adults are at risk of inadequate nutrition. Know the causes and signs of nutrition problems in older adults, as well as steps you can take to ensure a nutrient-rich diet for an older loved one.

Problems caused by malnutrition

Malnutrition in older adults can lead to various health concerns, including:

A weak immune system, which increases the risk of infections

Poor wound healing

Muscle weakness, which can lead to falls and fractures

In addition, malnutrition can lead to further disinterest in eating or lack of appetite — which only makes the problem worse.

Malnutrition is a serious senior health issue. Know the warning signs and how to help an older loved one avoid poor nutrition.  Next week we will focus on how malnutrition begins.

How Mom’s Meals NourishCare Gets Nutritious Food to Your Table

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Much like the meals you make at home, Mom’s Meals NourishCare prepares meals from fresh ingredients that are purchased from our local suppliers. For some recipes, we go through a pallet of fresh green peppers, cleaning and trimming just like you do at home. Meal components are made and then plated under the direction of Quality Assurance chefs, who are formally trained and come from restaurant backgrounds.

Prior to the finalizing a recipe, we go through a rigorous testing process to come up with the finished product. First, we determine our target meal nutritionals. For this process, we always use reputable sources, such as American Heart Association or American Diabetes Association. Once the chefs and dietitians determine the nutritional profile of the meal, a brainstorming session occurs in which some general meal concepts are developed.

During this process, we may go to local restaurants and grocery stores to sample comparable foods that have the flavor but not necessarily the “right” nutritional composition. You would be amazed at the sodium and fat content of some commercially available products – heart attacks in a jar. We recently reformulated our marinara sauce and in doing so tasted 15 different brands of marinara. What was amazing to us was that some of the commercial brands had over 1,000 milligrams of sodium per serving!  Who Knew?

Once we have a chance to taste and evaluate commercial samples, our chefs produce a couple of versions, looking for the “gold standard” that reflects both nutritional requirements as well as great taste. This recipe is tasted and evaluated by our employees (their favorite part of their job) and then customers. Once we have the final stamp of approval from them, the recipe is scaled and piloted in the kitchen to ensure that we can produce it in quantity for our customers.

A lot of time and effort is put into each meal — just like Mom made it herself.

The Critical Role of Good Nutrition in Chronic illness and Disease An Interview with Sam Beattie, PhD, Food Science Expert

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When someone is diagnosed with a chronic or potentially life-threatening disease, their nutrition plays a critical role in their recovery. We asked Dr. Sam Beattie Ph.D. for his view on the topic, as he is an expert in the field of food safety and quality and is the Director of Nutrition Services and Education at Mom’s Meals NourishCare.

Dr. Beattie received his undergraduate degree in Food Technology from Iowa State University, his Master’s degree from South Dakota State University, and his PhD from Oregon State University in Food Science and Technology with minors in Biochemistry and Microbiology.

“Healthy eating is critical to all, and for those with a chronic illness, eating the appropriate diet can have significant impacts. For example, recent clinical studies by Dr. Scott Hummel at the University of Michigan have shown that a low sodium diet can actually improve heart function in those diagnosed with a specific type of heart failure. Consuming the appropriate nutrition can mitigate symptoms, slow disease progression and, in some cases, even reverse signs of the disease in some chronic conditions such as renal failure, diabetes, obesity, heart disease and high blood pressure.”

The root cause for many chronic diseases is, in fact, poor nutrition. Consider the incidence of obesity, high blood pressure, and heart disease — these are almost always caused by poor food choices and the amount consumed.

Nutrition is equally critical in recovery from a hospital stay or surgery, as it is central to supporting the body’s ability to heal itself. Before starting Mom’s Meals NourishCare or making a change to your diet, we recommend talking to a physician and dietitian regarding the best nutrition plan for your particular circumstance.

Narrowing the Malnutrition Gap

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By Staci Hemesath, Board Certified Specialist in Renal Nutrition, Registered Dietitian

Based on new research published in the Journal of Parenteral and Enteral Nutrition (Corkins, et al., 2014), there is an alarming number of undiagnosed malnourished patients in U.S. hospitals. Findings from the 2010 Healthcare Cost and Utilization Project revealed that only 3.2% of hospitalized patients were correctly coded as malnourished.

The Malnutrition Gap

But how many patients arrive at the hospital malnourished? Between 33%-54%, depending on the study.  This means roughly 1/3 to 1/2 of hospitalized patients are not being properly coded as malnourished! Plus, among patients that are not malnourished upon admission, approximately one third may become malnourished while in the hospital.

If left untreated, two thirds of these malnourished patients will suffer a greater decline in nutritional status during their hospital stay. This translates to a significant number of patients leaving the hospital in a nutritionally compromised state.

As an outpatient dialysis dietitian, I have witnessed the post-discharge downward spiral of many of my patients. It’s concerning that they go to the hospital to “get better,” but often leave in a weak, malnourished state.  And in many cases, they either:

1) Get readmitted after suffering a fall at home or being diagnosed with an infection or

2) Get admitted to a nursing home with a further decline in functional status

It is sad to see and makes me ponder what can be done to improve this reality.

This “malnutrition gap” reveals a tremendous opportunity to optimize quality of patient care, improve clinical outcomes, and reduce cost.  My example above highlights a few of the common adverse outcomes of malnutrition, but there are many others.

Prompt Diagnosis is Critical – New ICD-10 Codes May Help

Identifying and treating malnutrition early on is a critical step in addressing hospital malnutrition.

  • New ICD-10 Codes:  A promising step in the right direction is the mandatory implementation of ICD-10 codes, effective October 1, 2015.  The new codes require users to more specifically define each health condition. In doing so, nutrition-related issues are more likely to be identified and institutions can be reimbursed appropriately.  Successful implementation of this process can result in significant gains in hospital revenue.

Nutrition Care Model: The Alliance to Advance Patient Nutrition, an interdisciplinary collaboration of the Academy of Nutrition & Dietetics and other industry leaders, has developed a nutrition care model (Tappenden, et al., 2013) with six principles designed to improve hospital nutrition practices. One of the key principles, which is often overlooked, is the inclusion of nutrition in the discharge planning process. Ensuring that nutrition is part of the transition to home is crucial in preventing hospital readmissions.

Patients and caregivers must be given detailed instructions for nutrition care at home, and nutrition should be an essential component of follow-up appointments. Also, dietitians should be involved in the care transitions process so that appropriate interventions can be implemented, recommended, and monitored.

Dr. Sam Beattie’s discussion of nutrition reconciliation sums up this process well.

The new ICD-10 Codes and the Alliance nutrition care model are some great tools to help combat malnutrition and improve outcomes.  What other tools or resources do you know of that could help?

Sources:

http://pen.sagepub.com/content/38/2/186.full.pdf+html

http://www.journals.elsevierhealth.com/periodicals/yjada/article/S0002-8223(00)00373-4/abstract

http://pen.sagepub.com/content/38/2/186

http://www.andjrnl.org/article/S2212-2672(13)00641-2/fulltext

http://www.journals.elsevierhealth.com/periodicals/yjada/article/S0002-8223(00)00373-4/abstract

CMS Policy Change – Dietitians to Order Diets

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By Staci Hemesath, Board Certified Specialist in Renal Nutrition, Registered Dietitian

Have you heard the good news? On May 12, CMS announced its final rule stating that “all patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals.

What Does This Mean For You?

If you are an RD/RDN or qualified nutritional professional (per State law) working in a hospital, you will have the independent authority to order therapeutic diets for your patients, including home-delivered meals, as long as you are granted privileges from your medical institution. No more delays in tracking down the busy physician or mid-level practitioner to discuss recommendations or have an order co-signed. If you identify a patient that would benefit from a therapeutic diet order or nutrition supplement, you will be able to order it on the spot.

A hospital can also grant dietitians/qualified nutrition professionals the privilege to order lab tests to monitor the effectiveness of dietary plans and orders, in accordance with individual state laws. Therefore, if you write orders for enteral or parenteral nutrition, you may also be able to write the follow-up laboratory orders to monitor blood glucose, pre-albumin, LFTs, etc. Upon reviewing results, you can then alter the diet order as warranted.

What Does This Mean For Your Patients?

How many times have your patients waited hours to have their diet liberalized, to advance from NPO, for nutrition support to be initiated, or for a supplement to be delivered, only because of a delay in tracking down a physician to co-sign a diet order? This greatly reduces patient satisfaction and jeopardizes their health.

CMS expects this new rule to greatly improve the efficiency and efficacy of nutritional care. CMS states, “The addition of ordering privileges enhances the ability that RDs already have to provide timely, cost-effective, and evidence-based nutrition services as the recognized nutrition experts on a hospital interdisciplinary team.”

Cost Savings Underestimated

The ruling could save up to $459 million in annual hospital costs, CMS estimates. However, this dollar amount is based solely on the difference in labor cost between a physician/MLP and RD ($291,104,100) and the estimated cost of reducing inappropriate parenteral nutrition usage ($167,730,675).

The savings is likely much greater when accounting for the reduced morbidity and mortality benefits, as predicted in some professional literature. Imagine a patient who lacks appropriate nutritional care while in the hospital, gets discharged in a malnourished state, suffers a fall at home, and is readmitted with a hip fracture. The cost of hospital readmissions, caused by poor nutrition, isn’t even factored into this cost savings estimate.

What You Can Do Now

The ruling officially takes effect on July 11, 2014. In the meantime, RDN’s will need to work on obtaining diet and laboratory ordering privileges from their medical institution.

If you don’t know how to get privileges granted to you, The Academy of Nutrition & Dietetics (AND) will be offering resources to assist in this effort.  For now, the ruling only applies to hospital dietitians, but AND will be working with CMS to extend authority to those working in long-term care facilities as well.

This policy change is a huge step forward for nutrition professionals. Dietitians ordering diets for their patients makes sense, doesn’t it?

Renal Diet 2.0

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By Staci Hemesath, Board Certified Specialist in Renal Nutrition, Registered Dietitian

For years, we’ve been discouraging consumption of whole grains, beans, and legumes in the CKD population. The rationale: These foods contain too much phosphorus and potassium and not enough protein, making it difficult for patients to maintain adequate albumin, while still keeping their mineral levels in check.

Well, it may be time to re-think this recommendation.

I had the opportunity to attend a fantastic session at the NKF Spring Clinical Meetings by Lisa Gutekunst, MSEd, RD, CDR, CDN, about the bioavailability of phosphorus in foods. Several newer research studies have suggested that plant-based proteins may have a place in the renal diet after all.

Unlike phosphorus from animal protein sources, which is easily absorbed by the body, phosphorus derived from plant protein sources is stored as phytic acid or phytate.  Humans do not produce phytase, the enzyme that degrades phytic acid, so the bioavailability of phosphorus from plant-derived food is relatively low, usually less than 50%.  For example: In a meal containing 50 g of white rice and 50 g of cooked lentils, there is approximately 180 mg of phosphorus and 16 g of protein. However, only 30% of that phosphorus is absorbed (54 mg). In this scenario, lentils could certainly fit into a renal diet, especially if potassium is well-managed or if the patient is on a home dialysis modality.

A whole new world of possibilities

While animal proteins are more efficiently utilized by the body, consuming a mixed diet of animal and plant proteins may have several positive implications.

  • Whole grains, beans, and legumes provide extra fiber that would aid in blood sugar control, lipid management, and minimizing constipation.
  • Patients with cultural or religious food preferences could safely include beans and lentils into their diets, thus improving their perceived quality of life and long-term adherence to the renal diet.
  • Beans and legumes are very inexpensive and would help patients plan menus on a tight budget.
  • A diet lower in animal fat may have anti-inflammatory properties.
  • Intake of fresh beans and lentils may decrease exposure to inorganic phosphates added to meat and poultry products.

More research still needs to be done in this area, but it’s exciting to know that under supervision, renal patients may be able to safely include a wider variety of nutrient-dense foods into their diets. Here’s to hoping that the days of the rigid renal diet are over – a “renal diet reboot.” I’d love to hear your thoughts.

Sources:

http://www.revistanefrologia.com/modules.phpname=articulos&d_op=&idarticulo=11918&idlangart=EN&preproduccion

http://www.ncbi.nlm.nih.gov/pubmed/23640120

http://www.ncbi.nlm.nih.gov/pubmed/21741857

http://www.ncbi.nlm.nih.gov/pubmed/21183586

http://cjasn.asnjournals.org/content/6/2/239.full