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

CMS-logo

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

driedbeans

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

Malnourished in the Breadbasket of the US – Food Deserts

By Dr. Sam Beattie, Nutrition Services

desert

I live in Iowa, in the heart of the breadbasket of America.  Iowa has some unique demographics in that we are one of the states with the highest percentages of older Americans.  Our rural population is shrinking with more young people moving either into the larger cities or completely away from the state.  This migration has caused small towns to lose services such as hospitals and grocery stores.  Most commonly lost are the Meals on Wheels type of home delivered nutrition programs, these are then followed by the loss of congregate meal sites.

Years ago, I had a chance to talk at a congregate meal site that was about to close because there was not anywhere for them to get their food.  The result is large areas where the local convenience store provides the menu, and it is neither inexpensive nor very healthy.  These are food deserts and not uncommon in many areas of the country, both rural and urban.  The USDA Economic Research Service has an interesting mapping tool to visualize where food deserts and food insecurity are prominent in the US.  

While it is counterintuitive that urban areas would be food deserts, there are many cities with areas that pose significant issues for elderly and others who need food.  Availability of transportation, cost of commercial property and presence of a high rate of poverty and other issues tend to drive larger chains from these market areas.

In some communities, various groups are “pushing back the desert” and helping provide ready access to healthy foods.  An example of this was recently reported as happening in South Los Angeles, California.  It took 17 years to get a viable grocery store in the food desert, but a grant through an investing fund, California FreshWorks, a locally staffed market has been opened.  Kaiser Permanente is a lead investor in the California FreshWorks Fund.

Mom’s Meals began providing food to hard-to-reach seniors in Iowa and Wisconsin over a decade ago.  We are also pushing back the food desert to allow the promise of the health that wholesome good food can bring.

blog map

Time Saving Tips for Kidney Diet Planning

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

Time-Saving

The renal diet has lists. Lots and lots of lists. While they seem simple enough to dietitians, they are confusing and overwhelming to patients. Patients want menus. They want personalized advice. They want help. And they need it.

The problem is that most renal dietitians are covering multiple dialysis clinics over a large geographic area, and it has become increasingly difficult to provide individualized menus to patients, taking into account food preferences, budget, time, and dietary prescriptions. Yet, we are ultimately responsible for patients’ lab outcomes.

So, how can renal dietitians help patients plan kidney-friendly meals and navigate this intricate web of a diet, in the most efficient, effective way possible?

Here are some resources and tips you can share with your patients or use in your practice:  

  • Online Menu Planning Tools: One option is www.davita.com/diethelper , which provides customized meal plans from a database of over 1,000 recipes (If a patient isn’t Internet-savvy, offer to guide them through it, and provide printed copies of meal plans.)
  • Kidney Diet App:  Download on a Smartphone that will track daily intake (e.g. KidneyDiet)
  • Home-Delivered Meal Service:  Refer patients to a service that offers renal-friendly meals, such as Mom’s Meals NourishCare, which offers a renal dietitian-approved menu specially designed to support those with kidney disease.
  • Prepare Extra Food:  Prepare large batches of favorite kidney-friendly recipes and freeze leftovers for later use. Best to do on days when they have more energy.
  • Network with other kidney patients, either in person or online, and share meal planning strategies, recipes and even grocery store circulars with kidney-friendly sale items.
  • Cookbooks & Recipes: Recommend the purchase of a kidney-friendly cookbook and/or offer copies of tried and tested recipes in your office or dialysis clinic. You may even want to feature recipes during a sampling day.

Living with chronic kidney disease is an immense burden. Adhering to a strict diet is one of the most difficult aspects of the disease.  For most, it is a life or death matter. Helping our patients plan enjoyable menus and inspiring them to try new recipes or sign up for a renal-friendly meal service will not only enhance their quality of life, but it may actually save their life.

Should “Nutrition Reconciliation” Become a New Industry Standard?
nutrition beth

By Dr. Sam Beattie, Nutrition Services

In recent US News and World Report and Wall Street Journal articles, it was cited that over 50% of hospitalized elderly are malnourished.  The Academy of Nutrition and Dietetics and American Society for ASPEN American Society for Parenteral and Enteral Nutrition define malnutrition as “the presence of two or more of these conditions: Insufficient energy intake; Weight loss;Loss of muscle mass;Loss of subcutaneous fat;Localized or generalized edema;Decreased functional status including grip strength”.  The result is most likely what is called Protein Energy Malnutrition (PEM), which is the greatest concern and identified as a cause of complications in readmits.

At the recent American Society for Aging conference in San Diego, Beth Burrough and I presented a workshop on the concept of Nutrition Assessment andReconciliation. Basically stated, how to identify who is malnourished and how to get the right nutrition to remedy it.This phrase was coined by Drs. Preston Maring and Phillip Tuso of Kaiser Permanente and is somewhat analogous to Medication Reconciliation.  Medication Reconciliation is designed to ensure that a patient’s medication history is identified and addressed in the hospitalization process.

Nutrition Reconciliation is the process of identifying and addressing the nutritional status and needs of the patient throughout the hospitalization cycle (at admissions, during and post-discharge) to best support the patient’s recovery and ability to control their condition as prescribed by their medical team.  This involves a simple screening for malnourished patients at admission.  Those patients who are at-risk for malnutrition are then fully assessed to determine if they require nutritional intervention by means of meals, calories, oral supplementation or even more drastic feeding tube or other.  Once the “Nutrition Prescription” is identified in the hospital, the patient is monitored and assessed for malnutrition before discharge.

The “Nutrition Prescription” follows the patient though the hospitalization cycle and to home.  The basic steps are: 

  • STEP 1 — Identifying patients who require nutrition support
  • STEP 2 — Creating a custom “Nutrition Prescription”
  • STEP 3 — Helping patients fill the “Nutrition Prescription”

By identifying the malnourished patient either before or at admission, a nutrition prescription can be requested to address the basic needs of the patient while in the hospital.  By filling the prescription with enhanced nutrition support, the nutritional status of the patient can be improved or maintained.  This will result in shorter length of stay, reduction in the likelihood of being readmitted and/or being admitted to a Long Term Care facility and having a poor overall outcome from the hospitalization.  Of course, the nutrition prescription must follow the patient into the post-hospitalization period.  Providing adequate nutrition to patients after discharge has clearly shown benefits on the outcomes and a reduction in readmission.

The bottom line is that through Nutrition Reconciliation and a nutrition prescription, we can reduce the cost of hospitalization and improve the quality of life for many of our most fragile folks.  The cost of feeding people one meal per day is less than $200/month while the average daily cost for long term care is approximately $4,500/month and hospitalization is over $7,000/stay.  Easy access to healthy, disease specific, ready to heat and eat food matters for making people better, happier and creating major Medicaid savings.

What’s Missing from the Proposed FDA Nutrition Facts Label?

FDA logo

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

As a renal dietitian, I know how hard it is for patients to follow a renal diet. It’s certainly a tricky one. How many people even know what phosphorus is before suffering kidney failure? And then there is potassium, sodium, protein, and fluid. Oh, but let’s not forget carbohydrate, sugar, and fat, as many kidney patients also struggle with diabetes and heart disease. To make it even more complicated, phosphorus and potassium aren’t even listed on food labels.

This is why the FDA’s proposal to update the current nutrition label is welcome news to the kidney community. The new labels would include potassium, calcium, and added sugars, helping fill in missing pieces of the renal diet puzzle. Vitamin D, a beneficial nutrient for kidney patients, will also be listed. Phosphorus is not part of the proposal, but the National Kidney Foundation has stated they will rally for its inclusion. (Wouldn’t that be wonderful?)

Be Heard – FDA Encourages Public Comments for Proposed Label

The FDA is accepting comments from experts and members of the public until June 2, 2014 before making the final ruling. This is your chance to weigh in and be heard by the FDA.

Click here to submit your comments (look for blue “Comment Now” Buttons).

Renal diet prescriptions would certainly be easier for patients to follow if they knew how much potassium, calcium, and phosphorus were actually in the food they purchased. For many, this is a life or death matter. On behalf of the 26 million Americans with chronic kidney disease, let’s speak up and bring forth change.

fda labels 2

Malnourished and ICU Lead to Very Poor Outcomes

By Dr. Sam Beattie, Nutrition Services

icu

For several years, we have been writing about how malnutrition impacts hospitalization and is a leading co-factor in readmissions.  A white paper outlining the evidence for the importance of nutrition in transition from the hospital is available here.

Now there is more evidence that malnutrition creates negative outcomes post discharge.  A clinical study conducted by researchers at Brigham and Women’s Hospital evaluated the nutritional status of patients admitted to Intensive Care Units (ICU) and determined outcomes for those patients.

The study compared ICU outcomes for patients who were not malnourished upon admission, to those with either protein energy malnutrition (PEM) or nonspecific malnutrition.  This was a relatively large study with over 3000 patients who survived hospitalization and were discharged into their homes.

Findings showed ICU patients who were malnourished upon admittance to ICU were:

  • More likely to be readmitted within 30 days of discharge
  • More likely to die within 90 days of discharge

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In looking at the data, it is clear that PEM upon admission to ICU is a contributor to readmissions and mortality in discharged patients.  Importantly, the study also found that use of various drugs increased with malnourished patients.

The researchers underscored the importance of post-hospitalization nutrition.  The fact that we discharge patients without knowing if they have food at home is a concern and has been shown to be a contributing factor to readmissions and emergency department visits.

Currently, estimates are that readmissions in the Medicare populations are costing $15 billion every year.  Simply feeding people prior to admission and post discharge could go a long way to improving outcomes and reducing overall healthcare costs in the United States.

Mogensen K, et al. “The association of malnutrition and 30-day post discharge hospital readmission in ICU survivors: A registry based cohort study” SCCM 2013; Abstract 54.

Investigation: Sodium in Full-Service Restaurant Meals

By Dr. Sam Beattie, Nutrition Services

chicken and pasta

A recent article in the Journal of Nutrition Education and Behavior provides some startling information about restaurant foods.  The investigators analyzed the nutrient content of meals at full-service restaurant chains (as opposed to fast food restaurants).

As part of the Affordable Care Act, restaurants (full service or fast food) with more than 20 locations will be required to provide nutrition information.

The findings from the investigation were that, on the average, full-service restaurant meals are extremely high in sodium at over 3500 milligrams and high in calories at nearly 1500 per meal.

For comparison, the American Heart Association recommendations for sodium intake are 1500 to 2400 milligrams PER DAY.  But the average citizen consumes around 3400 milligrams each day, which is too much.

Further, the average citizen needs only 2000 calories PER DAY.  Eating a typical restaurant meal leaves only 500 calories for breakfast, lunch and snacks.

I read the article with some skepticism.  We see these “OMG” releases fairly frequently.  This one struck a note with me since the sodium was so high in the restaurant meals, with the average meal having over 4 times the recommended level of sodium per meal.

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I think that if it is necessary to eat at full-service chain restaurant or a fast food restaurant, I will pay very close attention to the nutrition facts and select those meals that are lower in sodium.

If you cannot cook your own meals, an alternative to eating out is finding restaurant-quality meals that meet your nutritional requirements, like those provided by Mom’s Meals.

Source: Nutritional Value of Meals at Full-service Restaurant Chains, Auchincloss,A., et al. Journal of Nutrition Education and Behavior Volume 46, Issue 1, Pages 75-81, January 2014

Over the river & through the woods to low sodium meals for Thanksgiving

low sodium thanksgiving

The last thing anyone wants to hear before Thanksgiving is diet advice.  But if you want to ensure a better chance that you’ll celebrate many more holiday seasons with your loved ones, consider cutting back on sodium, starting now.

Heart disease, cardiovascular disease, high blood pressure, stroke, and other heart-related ailments are America’s number one killer. 

A recent study conducted at the University of Michigan, showed that healthy eating habits can significantly reduce high blood pressure and improve heart function, even in heart failure patients.

“We all look forward to sharing a feast with those we love,” said Rick Anderson, president of Mom’s Meals.  “But that doesn’t mean we can lose sight of what’s most important to our health, especially if we want many more years with those gathered around the table.  Cutting back on salt, which hides in so many of our foods, is crucial.”

The Michigan study had patients only eat meals prepared for them in the kitchen of the university’s Clinical Research Unit, and according to the DASH (Dietary Approaches to Stop Hypertension) recommendations.  Meals were high in potassium, magnesium, calcium, and antioxidants, and low in sodium, with just 1,150 milligrams or less, far lower than the average intake of an American adult of 4,200 mg a day for men and 3,300 a day for women.

Most participants in the study were in their 60s and 70s.  

In the study, participants only ate the provided diet, which met the recommendations for high blood pressure treatment by the American Heart Association and the U.S. National Institutes of Health. After three weeks, they saw a drop in blood pressure, similar to that achieved by taking medication for the condition, suggesting that diet plays an important role in the progression of heart failure.

“It is interesting to note that a change was seen in only three weeks,” said Anderson.  “Our heart-healthy menu has meals with 600-mg or less of sodium, and feedback on their taste has been nothing less than stellar.”