Symposium 4 - bapen.org.uk · Waterlow, Lancet 1972 needs to be standard classification of PCM •...

Symposium 4 Food for Thought – Challenging problems in Malnutrition

Malnutrition: a growing concern

Dr John Puntis

Malnutrition in hospital

• definitions of ‘malnutrition’

• where have these come from?

• clinical surveys

• nutritional screening

• summary


• “the prevalence of malnutrition in paediatric hospitals ranges from 15%-30% of patients”



• “malnutrition among hospitalised children is often unrecognised and therefore not treated”


• “malnutrition is bad for you”


• “malnutrition among hospitalised children is often unrecognised and therefore not treated”


• impaired immune responses

• reduced muscle strength and fatigue

• reduced respiratory muscle strength

• impaired thermoregulation

• impaired wound healing

• impaired psycho-social function

• growth faltering


• increased hospital stay

• increased costs

• justification for ‘screening’?

• evidence in the main from adult studies


• how do we link nutritional status to outcomes in children?

• how much malnutrition is bad for you?




• if we cant link malnutrition to outcomes, what point ‘screening’?




• if we cant link malnutrition to outcomes, what point ‘screening’?

however:

• a priori argument for preventing or reversing growth faltering


• classification of malnutrition?

• do we all agree?


• classification of malnutrition?

• do we all agree?

• problems of definition

• different types of malnutrition:


Malnutrition

• under nutrition, due to deficiency of nutrients

• over nutrition, due to an excess of nutrients

• micro-nutrients (trace elements and vitamins)

• macronutrients (protein, fat carbohydrate)

• clinical

• subclinical


Malnutrition

• under nutrition, due to deficiency of nutrients

• over nutrition, due to an excess of nutrients

• micro-nutrients (trace elements and vitamins)

• macronutrients (protein, fat carbohydrate)

• clinical

• subclinical

• some definitions . . . . .


“A continuum that starts with a nutrient intake inadequate to meet physiological requirements, followed by metabolic and functional alterations and in due course by changes in body composition”.


“A state of nutrition in which deficiency, excess or imbalance of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome.”


• form

• function

• clinical outcome


• form

• function

• clinical outcome

• malnutrition is difficult to define


Most obvious and earliest signs of malnutrition in children:

• absence of normal weight gain

• weight loss

• visible decrease in fat; loss of muscle


Most obvious and earliest signs of malnutrition in children:

• absence of normal weight gain

• weight loss

• visible decrease in fat; loss of muscle

• malnutrition commonly defined in terms of anthropometry (arbitrary cut offs)


Gomez, Journal of Tropical Pediatrics, 1956

• Mexico city; underfed children

• Boston growth standards

• 1sto – weight 76-90% average for age

• 2ndo – weight 61-75% average for age

• 3rdo – weight <60% average for age

• higher death rate 3rdo v 2ndo (22.6% v 33.5%)


Gomez, Journal of Tropical Pediatrics, 1956

• Mexico city; underfed children

• Boston growth standards

• 1sto – weight 76-90% average for age

• 2ndo – weight 61-75% average for age

• 3rdo – weight <60% average for age

• higher death rate 3rdo v 2ndo (22.6% v 33.5%)

• link between nutritional status and outcome


Jelliffe, WHO Monograph 53, 1966

Assessment of the nutritional status of the community (with reference to field surveys in the developing world)

• ideally local reference population data

• age may not be known accurately

• defining nutritional status of a community


Waterlow, Lancet 1972

needs to be standard classification of PCM

• defining prevalence in different countries/communities

• purpose: planning prevention

• community: mild, moderate, severe

• severe cases: qualitative classification to distinguish marasmus, kwashiorkor and intermediate


8th report of FAO/WHO Expert Cttee Nutrition

• height/length important

• reflects duration of malnutrition

• weight as percentage of expected weight for given height – acute malnutrition

• height as percentage of expected height for age (where age available) – chronic malnutrition

Waterlow, Lancet 1972

Guide to action at a public health/community level

normal, and

mild

malnutrition


McLaren and Read, Lancet 1972

• incorrect to assume that all children of same length should have the same weight

• relationship of weight with height varies with age

McLaren and Read WWC. Lancet 1972

Nomogram for categorising PCM

3 x as much moderate malnutrition!

Minor changes in arbitrary ‘cut offs’ = large differences

WHO Classification

____________________________________________________________

classification

_________________________________

moderate severe

____________________________________________________________

symmetrical oedema no yes

weight for height -3SD - -2SD SD <-3 (<70%)

(70 - 79%) (severe

wasting)

height for age -3SD - -2SD SD <-3 (<85%)

(85 - 89%) (severe

stunting)

____________________________________________________________

Seal A. Institute of Child Health, London, 2008

Impact of using WHO growth standards


Merritt RJ. Am J Clin Nutr 1979

• Children’s Hospital Medical Centre, Boston

• all patients > 3 mo

• Waterlow criteria

acute malnutrition (wt for ht <90%) 36%

chronic malnutrition (ht for age <95%) 47%


Moy RJD. J Hum Nutr Dietet 1990

• Children’s hospital, >3/12; NCHS; WHO

acute malnutrition (wt for ht <-2SD) 14%

chronic malnutrition (ht for age <-2SD) 16%

scores -1 - -2 SD = “at risk” from

decreased intake, increased requirements,

or losses 20%

• N.B. severe malnutrition mainly chronic disease


Hendrickse WH. Clin Nutr 1997

• Children’s hospital;

acute malnutrition (wt for ht <5%) 16%

(<-2SD 11%)

chronic malnutrition (ht for age <5%) 15%

(<-2SD 8%)

“at risk”(-1 -2 SD, ht +/- wt for age) 16%


Sermet-Gaudelus. Am J Clin Nutr 2000

• Children’s hospital; >1m

• % ideal body weight; French standards

• underweight 85-90%; mild undernutrition 80-84%; moderate 75-79%; severe <75%

Malnutrition (PIBW <85%) 26%

Waterlow: 80-90%; 70-80%; <70%


Pawellek I. Clin Nutr 2007

• Children’s Hospital; German standards; all admissions; Waterlow

mild malnutrition (wt for ht 81-90%) 17.9%

moderate malnutrition (70-80%) 4.4%

severe malnutrition (<70%) 1.7%

(24.0%)

• NB: greatest risk in complex patients


Joosten KF. Arch Dis Child 2010

• national; paediatric units; >1m; Dutch standards; WHO criteria

acute malnutrition (wt for ht <-2SD) 11%

chronic malnutrition (ht for age <-2SD) 9%

NB: 44% underlying chronic disease


What is ‘nutritional screening’?

rapid, simple and general procedure used by nursing, medical or other staff, often at first contact with the patient, to detect those with significant risk of nutritional problems, so that clear guidelines for action can be implemented


Hulst JM. Clin Nutr 2010

• Dutch STRONGkids nutrition screening score

• “to prevent malnutrition along with its complications early identification of nutritional depletion is essential”

• at risk of developing malnutrition: 62%

• median hospital stay 2 days for ‘low risk’, 3 days for ‘high risk’


What is being at ‘nutritional risk’?



• not the same as actually being malnourished




• are screening tools good at predicting health outcomes related to nutritional status?





• requires thorough testing, because purpose is to change outcomes





• requires thorough testing, because purpose is to change outcomes

• how many children with “mild malnutrition” are ‘thin’? how many show catch up after an acute illness?


Are there other indicators of ‘body form’ that might predict outcome?

Categories of BMI for identifying chronic protein-

energy malnutrition in adults ___________________________________________________________

BMI Weight Interpretation of status

(kg/m2) category

___________________________________________________________

<18.5 Underweight chronic under-nutrition probable

18.5 - 20 Underweight chronic under-nutrition possible

20 - 25 Desirable weight chronic under- or over-nutrition

unlikely (low risk)

25 - 30 Overweight increased risk of complications

associated with overweight

>30 Obesity risk of obesity related complications

____________________________________________________________

Briend. Brit Med J 1986. Usefulness of nutritional indices and classification

in predicting death of malnourished children. (Dhaka, n = 352)

arm circumference

weight for age

weight for height

height for age


What we don’t have

• a shared understanding of what it means to be ‘at risk’

• a universally agreed definition of malnutrition

• a clear link between ‘malnutrition’ and clinical outcomes

• a cogent argument for ‘screening tools’ as opposed to universal nutritional assessment


Summary and conclusions

• definitions of malnutrition based on anthropometry will remain arbitrary until they are linked to clinical outcomes

• estimates of hospital malnutrition vary according to definitions used/reference data

• more recent use of WHO criteria give lower rates than in earlier studies


Summary and conclusions

• a priori case for avoiding or reversing growth failure

• growth monitoring (linked to action plans) should be routine for all patients


Jelliffe, WHO Monograph 53, 1966

Nutritional anthropometry:

“The interpretation of findings is always complex and often controversial even to leading authorities. The normal healthy well-fed human body can vary so much that interpretation of the nutritional significance of variations in physical dimensions is peculiarly difficult”.

Common classification of protein energy

malnutrition (children)

___________________________________________________________

Normal Mild Moderate Severe

___________________________________________________________

Weight for height* 110-90 90-85 85-75 <75

Weight for age 110-90 90-81 80-61 <60

Weight for age✚ >90 90-75 75-61 <60

Height for age⌘ >95 95-87 87-80 <80

Weight for height⌘ >90 90-80 80-70 <70

___________________________________________________________

presence of oedema = kwashiorkor; no oedema = marasmus

* McLean 1975; Jelliffe1966; ✚ Gomez 1955; ⌘ Waterlow 1972

Child Under-Nutrition in

Affluent Societies: what are we

talking about?

Charlotte M Wright

Ada Garcia

School of Medicine,

Glasgow University

How common is undernutrition?

• Prevalence varies from <1% to 12%

• Depends on measure used:

– Wt, Ht/Length, BMI, WFH, Centile falls, conditional SD change

• Threshold

– 2nd, 3rd, 5th

• Growth reference used

– WHO/CDC 1978, CDC, WHO 2006, IOTF, UK 1990, French

What is under-nutrition?

• No gold standard test

• A net deficit of energy (and other nutrients) resulting in

– Loss of /failure to acquire fat stores

• Depending on severity /duration /age, may also cause

– Slow growth

– Low lean mass

– Metabolic derangement, immune suppression, catabolism

Wasting – low BMI /WFH

• Assumed to reflect low fat

• Sound method to identify acute

malnutrition when under-nutrition

prevalence is high

• Little used in UK till recently

• Little known about clinical significance

Failure to thrive/ weight faltering

• More known about clinical significance

• Variability in how defined and understood – Low weight for age over-identifies infants with low

birth weight

– Centile falls over-identify initially large infants

– Conditional weight gain used for research purposes

• Primary care definition – Fall through 2 centile spaces

– (3 if >91st, 1if <9th)

– But prevalence varies with growth reference used

Natural history of weight faltering

(slowest gaining 5% N=215)

-3

-2.5

-2

-1.5

-1

-0.5

0

0 6 12 18 24 30 36 42 48

Age in months

Mean (

SE

) W

eig

ht

SD

S Whole

cohort

P=0.019

Home visit

P=0.044

Intervention

Intervention

Controls

What causes weight

faltering? • Associated with relative undernutrition

– 2/3 show some evidence of low intake

– Low appetite, feeding behaviour differences

• No clear relationship (in UK) with deprivation

• 5% have other evidence of abuse or neglect – Look for recovery with change of care

• 5-10% cases have symptoms or signs of underlying disease – But if they look well they are well

• How many of the remaining 85% are truly undernourished?

So how common is true

undernutrition in childhood?

• Concordance of weight faltering, wasting

and stunting with fat levels in two

population based cohorts

• Gateshead Millennium Study

– ≈ 860 subjects with anthropometry

aged 1 year

– ≈ 600 with body composition measures

aged 8 years

• ALSPAC

– ≈7,000 children with body

composition measures aged 7-11

ILLENNIUM BABY STUDY

Wasting <2nd centile for BMI

(UK 1990)

Sustained weight

faltering <5th internal centile for

conditional weight gain since

birth at 2 or more ages

Concurrence of different definitions in

GMS cohort

Stunting <2nd centile for length

(UK 1990)

0.6% (5)

4.1% (35) 3.8% (32) 1.8%

(15)

0.4% (3)

0.1% (1) True

undernutrition?

Prevalence = 2.3%

How different measures of undernutrition in infancy relate to

growth and body composition outcomes aged 8 years

-2.00

-1.33

-0.66

Weight BMI Adiposity Lean (BIA) Height Mid parental

height

Z s

co

re

BMI<2nd only (35) Weight faltering only (32) WF plus low BMI or stunting (19)

Wasted =

low average fat

and lean mass

Weight faltering =

low average height but

proportionate to parents

How different measures of undernutrition in infancy relate to

growth and body composition outcomes aged 8 years

-2.00

-1.33

-0.66

Weight BMI Adiposity Lean (BIA) Height Mid parental

height

Z s

co

re

BMI<2nd only (35) Weight faltering only (32) WF plus low BMI or stunting (19)

Short and shorter

than parents

Weight faltering+ = low fat and lean mass

ALSPAC study

Ages 7-11 years

19% <2nd

have low fat

46% above 95th

have high fat

79% of those

<BMI 2nd,

were >fat 5th

centile

52% of those

<BMI 2nd,

were <lean

5th centile

Does a low BMI in

childhood?

actually reflect low

reserves

79% of those with

BMI below 2ndcentile

were above fat 5th

centile

52% of those

with BMI

below 2nd

were below

lean 5th

centile

Concurrence of low BMI and fall in BMI with

low body fat in ALSPAC, aged eleven


(UK 1990) Low fat <5th internal centile for

fat (BIA) adjusted for

height, age, gender

BMI SD change <5th internal centile

4.0% (237)

1.0% (62)

4.9% (291)

0.12%

(7)

0.74% (44)

0.18%

(11)

0.08% (5)

True undernutrition?

Prevalence = 1.12%

Concurrence of low BMI and fall in BMI with

low body fat in ALSPAC, aged eleven


(UK 1990) Low fat <5th internal centile for


height, age, gender

BMI SD change <5th internal centile

4.0% (237)

1.0% (62)

4.9% (291)

0.12%

(7)

0.74% (44)

0.18%

(11)

0.08% (5)

True undernutrition?

Prevalence = 0.38%

How should under-nutrition be

diagnosed?

Sceptically, without relying on a single

measure

Weight trajectory

BMI

Skinfolds (DXA / BIA)

Response to treatment

Functional assessment

Undernutrition in childhood in

the UK

• Still present in ≈ 2% infants, <1% children

• Many screen positive cases are not

undernourished at all

• Most of rest are only mildly undernourished

– Assess sensitively

– Treat proportionately

• A few will have organic disease or be suffering

neglect

– Look for supporting evidence

– Not a diagnosis by exclusion

My thanks to:

• All involved with Gateshead Millennium and ALSPAC studies

Funders

• Henry Smith Charity

• SPort Aiding Research in KidS

• Newcastle, North Tyneside and Northumberland NHS R&D

• Scottish Chief Scientists Office

• NPRI

• British Heart Foundation

WHO 2006 standard describes how all children <5 years should grow

Impact of new WHO standard

• Reduces prevalence of low weight, BMI or WFH

compared to earlier standards

– But increases prevalence of wasting <6m

• WHO estimates of prevalence in affluent

countries

– Low weight for age (-2SD) 1.6%

– Stunting (height for age <-2SD) 6%

• BMI /WFH from single studies (UK, USA)

– 4m 2 %

– 8m onwards <1%

Concurrence of wasting and stunting

with low body fat in ALSPAC aged Seven


(UK 1990)

Low fat <5th internal centile for


height, age, gender


(UK 1990)

1% (81)

0.9% (68)

4.7% (364)

0.26%

20

0.07% (6)

0.03% (2)

Concurrence of low BMI, fall in BMI and

stunting with low body fat in ALSPAC aged

eleven


(UK 1990)

Low fat <5th internal centile for


height, age, gender


(UK 1990)

0.62% (45)

1.5% (108)

4.6% (335)

0.37%

(27)

0.1% (7)

0.03% (2)

0.01% (1)

Roswyn Hakesley-Brown

CBE MPhil, BA, RN Chair, The Patients Association

The Prevalence of

Malnutrition in

General Practice

Paula McGurk PhD RD

Research Dietitian

University Hospital Southampton NHS

Foundation Trust

Professor Marinos Elia

Dr Abbie Cawood

Dr Rebecca Stratton

Distribution of Malnutrition in the UK

according to Care Setting

~2% hospital

~5% care homes

~93% community (2-3% sheltered

accommodation)

(Elia & Russell, 2009)

Prevalence of Malnutrition in General

Practice (GP)

Few reports (Edington et al 1996; Martyn et al 1998; Turnbull & Sinclair 2002)

Often reported in specific patient groups and

populations, e.g. malnutrition in cancer patients

Inconsistency in patient selection procedures and

methods of identifying malnutrition

No reports of large series involving patients

consecutively visiting their GP, screened using

consistent criteria, such as those in ‘MUST’

Aims

1. a) What is the prevalence of malnutrition in

people visiting their GP and to what extent is it

identified and treated?

b) How representative is the study population of

the general population in England?

2. Is malnutrition related to health outcomes and

healthcare use?

k

Methods

Developed a questionnaire

Attended a Practice Manager forum

6 General Practices agreed to host

Visited surgeries (Nov ‘10- May ’11)

General characteristics

Age, gender, GP

Postcode

*Health Outcomes

Unhealed wounds,

Infections, Weight loss

*Healthcare use

GP visits

Antibiotic use

*In the previous 6 months

Methods

Weight, Height and Weight loss (used data to

apply ‘MUST’ criteria)

Rank of Index of Multiple Deprivation Score

established using GP postcode

(1 (most deprived) - 32,482 (least deprived) )

(Nobel et al 2011)

Health outcomes & healthcare use: Questionnaire

Results 1a: Patients

146 were

relatives/carers/

friends

970 invited to

participate

601 (62%)

screened

455 were

attending for an

appointment

Variable Mean SD

BMI

(kg/m2) 26.3 ± 5.3

Weight

(kg) 73.9 ±17.1

Age (yrs) 41.8 ±18.3

369 (38%) did

not participate

6.2%

4.6%

0

2

4

6

8

10

12

%

High risk

Medium risk

Results 1a: Medium and High risk patients

(n 455)

‘MUST’ category

10.8%

Results 1a: Prevalence of Malnutrition

(M+H risk)

(n 455)

Step 1; BMI contribution

to MUST: 39 / 455 (8.7%)

Step 2; Weight loss

contribution to MUST:

14 /455 (3%)

Step 3 Acute disease

score effect; No

contribution

7.8% 2.1%

Wt loss

3%

Overall prevalence 10.8% (95% CI 8.2% 14.0%)

0.9%

8.7%

BMI

LEAST

DEPRIVED

MOST

DEPRIVED

1

32,482

Average in England (16,241)

General Practice (4474 – 14811;

mean 8138)

1.b: Rank of Index of Multiple Deprivation Score

Results 2: Health Outcomes and

Healthcare use (last 6 months)

2.2%

16.7%

60.6%

8.2%

24.5%

65.3%

0

20

40

60

80

Unhealed wounds

Infections requiring Abx

≥1 GP visit in last 6 months

% o

f p

op

ula

tio

n

Low risk

Med & High riskSignificantdifference(P<0.05)

P=0.23

P=0.64

Discussion and conclusion

1. a) Prevalence of malnutrition in those attending

the GP is 10.8% (95% CI 8.2%, 14.0%), all of

which was unrecognised and untreated.

b) All practices were located in areas of higher

deprivation (caution in generalisations)

2. Current malnutrition tended to be associated with

adverse health outcomes and increased

healthcare use during previous 6 months.

References

Elia M (Editor) 2003 The ‘MUST’ report. BAPEN, Redditch.

Elia M & Russell C.A (2009) Combating Malnutrition:

Recommendations for Action.

Nobel et al (2011) Indices of Deprivation 2010 for Super

Output Areas (www.communities.gov.uk)

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