Malnutrition in the hospital


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Malnutrition in the hospital

  1. 1. Malnutrition in the Hospital DTC 671 4/8/2010 Corrie CoxPg. 1
  2. 2. Malnutrition is a condition in which your body is not getting enough nutrients; and is aresult of an inadequate or unbalanced diet, problems with digestion or absorption, and certainmedical conditions (1). Symptoms of malnutrition vary but can include the following: fatigue,dizziness, weight loss, loss of hair, lack of menstruation, and lack of growth in children (1).Tests to determine malnutrition are nutritional assessments and blood work (1). Dependingon the severity of the condition, treatment typically consists of replacing lost nutrients, treatingthe symptoms, and treating any medical conditions associated (1). If left untreated,malnutrition can lead to possible complications such as mental or physical disabilities, illness,and even death (1). In a clinical setting, poor nutritional status in a patient has beenestablished as an indicator for an increase in complications (2). In addition, poor nutritionalstatus has also been associated with higher rates of infection, poor wound healing, longerhospital stays, and even cardiac complications (2). Current interventions such as protectedmeal times, more menu items, additional snacks, encouraging patients to eat, and even sipfeedings have been used to prevent weight loss(2), but the best way to prevent malnutritionis through eating a well balanced diet (1). In 2009, the European Society for Clinical Nutrition and Metabolism published amultinational one-day cross-sectional survey referred to as NutritionDay (2). The survey,which involved 25 countries, took place on January 19th, 2006 and involved 16,455 adulthospitalized patients (2). The main focus of the survey was the effect of food intake andnutritional factors on death in a hospital setting (2). NutritionDay utilized members of theinterdisciplinary team and patients which filled out three questionnaires to obtain data (2).Pg. 2
  3. 3. The first questionnaire described the facility where the patient was staying, the second wasthe caregivers view of the patient (age, height, weight, medical condition, comorbidities, andtype of nutritional intake), and the third questionnaire allowed patients to report their foodintake on NutritionDay (2). The outcome assessment following NutritionDay lasted for 30days to determine the odds ratio for dying (the effect of the amount of the meal eaten onmortality) (2). Food intakes on NutritionDay showed that less than half of the patients finishedtheir meals (2). Patients that reported eating less than half of their meals, or nothing at all,commonly stated the reason was “not being hungry,” “dont like the taste,” “normally eatingless,” “dont want to eat,” and “having nausea (2).” During the 30 day outcome assessment,20% of patients who did not eat at all started receiving artificial nutrition, and 5-8% who ateless than half of their meals also received artificial nutrition (2). At the end of the study 634patients (3.9%) died, and the odds ratio for dying increased as the amount of food consumedon NutritionDay decreased (2). The study concludes that decreased food intake and alterednutrition status remains to be a problem within European hospitals (2). As a result, patientsare at higher risk for mortality and macro/micro nutrient deficiencies (2). Just like vital signs,the study suggests the fractions of meals eaten, for at least one meal, should be recorded inpatient charts and may even trigger early nutrition intervention (2). In 2008, The Journal of Nutrition, Health, and Aging published the article titled, “ WhyDont Elderly Hospital Inpatients Eat Adequately (3)?” The article states that malnutrition iscommon in elderly hospitalized patients, which in turn results in poor clinical outcomes (3).The objective of the study was to gain an understanding of why poor nutrition intake in theelderly population occurs in a hospitalized setting, and what are the consequences of poorintake(3). For the duration of 4 weeks, 100 patients (mean age of 81.7 years) were observedPg. 3
  4. 4. twice a week from admission to discharge; and their intake was reported throughobservations, food-charts, case-notes, and through interviews with the patient/caregivers (3).Additionally, reasons for inadequate intake was recorded (3). From the data provided it wasdetermined whether the patient ate at least ¾ of their diet along with prescribed supplements,and if the patients ate less than this amount, inadequate nutrition was documented (3). Theresults of the study showed that upon admission, 21 patients were malnourished (based onheight and weight below the 10th percentile), 3 patients became malnourished during theirstay at the hospital, and 67% of patients were reported to be eating inadequately (285/425assessments were made) (3). The most common reasons for inadequate intake during theearlier part of the patients hospital stay was the following: acute illness, anorexia, oralproblems, and catering limitations (3). Throughout the duration of the study, the mostcommon reason for inadequate intake were: confusion, low mood, and dysphagia (3).Moreover, in comparison to well nourished patients, malnourished patients had a highernumber of oral problems (3). Ney D et al., published a review titled, “Senescent Swallowing: Impact, Strategies, andInterventions,” which discussed the increased risk of oral problems accompanied by age (4).Dysphagia, difficulty swallowing, occurs in the elderly population and is a result of the loss ofskeletal muscle mass and strength (4). Patients will often develop a fear of eating, animpaired ability to eat, or even anorexia (4). Dysphagia plays an important role on the effectsof a patients nutrition status and if untreated or undiagnosed, it can lead to dehydration ormalnutrition (4). Specifically, dysphagia can lead to an increased risk of protein-energymalnutrition that often leads to weight loss, muscle breakdown, dehydration, fatigue,aspiration pneumonia, and an overall decline in the patients ability to function (4). The reviewPg. 4
  5. 5. discussed a recent study that identified dysphagia and the loss of skeletal musclemass/strength as a predictive of hospital acquired infections (4). In addition, untreated orundiagnosed dysphagia, which progressed to protein-energy malnutrition, increased themorbidity and mortality rates of patients in a clinical setting (4). Not only is malnutrition a concern in the elderly population, but also in infants andchildren. Barron M et al., wrote an article titled, “ Nutritional Issues in Infants With Cancer,”which states that cancer and cancer therapies can also play a role in malnutrition in childrenand infants, especially since they have limited energy reserves (5). Furthermore, chronicmalnutrition can effect weight gain, growth, daily interactions, and overall quality of life (5).Undernutrition, which can lead to malnutrition (prolonged slow weight gain compared togrowth), is a concern for infants since the first two years of life consist of rapid weight gainand growth (5). By age three, if a child is still malnourished brain growth can be effected (5).In a hospital setting, for children with cancer, G-tube feedings have been an effectiveintervention for weight gain, if the gut is functioning (5). Each feeding is individualized forfeeding schedules and formulas, and frequent adjustments may need to be made in order toachieve effective weight gain (5). Typically, patients will eat during the day and feeds will besupplemental (5). In the case of chemotherapy, which can decrease a patients appetite, tubefeeds will be increased to make up for the decrease in oral intake (5). If the gut isnonfunctioning, total parenteral nutrition (TPN) has also been proven to be an effectiveintervention for weight gain in children, specifically cancer patients (5). However, adequatecaloric and protein intake must be met, and it is important to calculate the amount of TPNactually received rather than what was ordered (5). In conclusion, adequate intake is crucialfor growth and development for infants and children, cancer and chemotherapy can causePg. 5
  6. 6. adverse effects on food intake, if intake is inadequate, consider G-tube feedings or TPN as asupplementation (5). In 2008, the study titled, “ Refeeding syndrome: A potentially fatal condition but remainsunderdiagnosed and undertreated,” discussed two case studies that involved a 70 year oldwoman and a 15 year old girl diagnosed with refeeding syndrome (6). Refeeding syndromecan occur in patients that have kwashiorkor, marasmus, anorexia nervosa, chronicmalnutrition, chronic alcoholism, chronic diarrhea and vomiting, oncology patients, some post-op patients, or those who have fasted for prolonged periods of time (7). In a clinical setting,after a period of starvation and weight loss, patients that begin enteral or parental nutritioncan experience abnormalities in electrolyte levels, glucose metabolism, and vitamin deficiency(thiamine is a common deficiency) (7). Furthermore, intracellular (cation and anion)imbalances such as hypophosphatemia, hypomagnesemia, hypokalemia occur duringrefeeding syndrome (7). Refeeding syndrome usually occurs within the first few days ofrefeeding, and clinical features are nonspecific and can be unrecognizable (7). Case 1involved a 70 year old woman with dysphagia, shortness of breath, lethargy, and ill health forthe the past four months (6). She had lost weight, the amount unknown, and had beendrowsy and breathless four days prior to admission (6). Her clinical examination did not showany abnormal blood tests, and her cardiovascular, pulmonary, and abdominal examinationswere unremarkable (6). However, she appeared to have decreased respiratory function and ahigh WBC count and she was transferred to the ICU (6). The patient was placed on a high-energy feeding and twelve hours later she developed a cardiac arrest, but was successfullyresuscitated (6). Over the next few days she remained drowsy, weak, and had severe muscleweakness (6). A consultation by the clinical nutrition team was ordered, and she wasPg. 6
  7. 7. diagnosed with severe malnutrition complicated by refeeding syndrome withhypophosphatemia, hypocalcemia, and hypokalemia (which led to worsening of herrespiratory function) (6). Her feedings were changed to high-protein, high-fat, and lowcarbohydrate and she was given calcium, phosphate, magnesium, and potassium infusionuntil her biochemistry values were within normal limits (6). Three days later she was weanedfrom the ventilator and transferred out of the ICU (6). Shortly there after she was sent homeon a normal diet plus oral nutrition supplements (6). Case 2 involved a 15 year old girl whorecently had a total colectomy due to severe ulcerative colitis and was admitted to the hospitalwith a 10 day history of nausea and vomiting, lower abdominal pain, severe diarrhea, andpoor oral intake which led to a significant amount of weight loss (6). Upon admission, sheweighed 25 kg, 146 cm tall, and her BMI was <11.7 (severely malnourished) (6). Her sodiumlevel was 131 mmol/L, potassium was 3.3 mmol/L, and her C-reactive protein was elevated(6). In addition, her electrolytes concentrations were low baseline, altogether this put her athigh risk for refeeding syndrome(6). The patient was started on IV fluids, potassiumsupplements, antibiotics, and a nutrition consult was ordered (6). She was than started on alow-calorie feeding through an NG tube and the feedings were gradually increased over a 4day period (6). At the same time she was also given B-vitamin supplements includingthiamine plus other multivitamins and trace elements, and her electrolytes were closelymonitored over the next four days (6). The patients diarrhea ended and her weight increasedby 4 kg (6). She was sent home on night tube feeds and free PO intake during the day (6).Not all patients who are refed will develop refeeding syndrome; however, these two casesshow the importance of considering refeeding sydrome when starting malnourished patient onenteral or parental nutrition (6). Refeeding syndrome is a potentially fatal condition thatremains underdiagnosed and undertreated, but if recognized can be treated and preventedPg. 7
  8. 8. (6). According to the article, “Concentrations of riboflavin and related organic acids inchildren with protein-energy malnutrition,” riboflavin, flavin mononucleotide, and flavin adenindinucleotide concentrations have not been studied in depth in relation to malnutrition (8). Theobjective of the study was to look into the effects of malnutrition on riboflavin status andriboflavins relation with thyroid hormones and concentrations of urinary organic acids (8).Clinical records, anthropometric data, and plasma nutritional protein concentrations wereobserved throughout the duration of the study (8). Vitamin deficiencies associated withprotein-energy malnutrition are Vitamin A,C,D,E, thiamine, and biotin (8). On the other-handvitamins B-12 and folate concentrations are usually found to be within normal limits orelevated during protein-energy malnutrition (8). Sixty malnourished children from thesavannah in Benin and the coast in Togo (both areas located in western Africa) wereexamined for the purpose of this study (8). Based on the Wellcome classification, which wasused to determine the types of protein-energy malnutrition; group S had 18 childrendiagnosed with kwashiorkor and 12 with marasmus, and group C had 6 children withkwashiorkor and 24 with marasmus (8). Anthropometric measurements were taken whichincluded weight, height, arm and head circumference, the ratio of arm to head circumference,and body mass index was calculated (8). The weights and heights were compared to the USNational Center for Health Statistics, and overnight fasting blood and urine samples wereobtained the morning after admission of the subjects (8). The data from the control groupcame from 23 healthy children of the same age from both the savannah and coastal regions(8). In both malnourished groups the quality of their intakes were recorded , and breast milkwas the main food source for children under the age of 24 months (8). After 24 months of agePg. 8
  9. 9. the main food sources in the diet consisted of rice or maize pudding, vegetables, and onoccasion powdered cows milk (8). The concentrations of riboflavin in maize, millet, and cowmilk are significantly higher than the concentrations found in rice and human milk (8).Anthropometric measurement were compared to the control group and both group S andgroup C had lower averages anthropometric averages when compared (8). As for comparinggroup S and group C, no significant differences were reported in their BMI values (8).Through blood and urinary samples that results showed that children in group S weresignificantly more malnourished than the children in group C (8). Low thyroid hormoneconcentrations were also reported in both malnourished groups, but group S appeared tohave lower T3 and T4 concentrations; in addition, children in group S and group C reported tohave iodine intake deficiency (8). Plasma nutritional protein concentrations were lower inmalnourished children when compared to the control group, and group S showed moresignificant affects than group C (8). Furthermore, in both malnourished groups plasmainflammatory protein concentrations were higher than in the control group (8). In group S, thechildren had lower plasma transferrin, albumin, and FAD, with a higher riboflavinconcentration reported in comparison to the control group (8). In addition, group C did nothave significantly lower transferrin, FAD, FMN, or riboflavin in comparison to the control group(8). Other lab values were reported; however, overall the study shows that a relationshipbetween riboflavin concentrations, thyroid hormones, and plasma nutritional proteins inrelation to protein-energy malnutrition (8). Prevention and identification of malnutrition in a clinical setting seems to be the focusof current studies taking place. A Dutch national survey called STRONGkids was developedas a nutritional risk screening tool to be used in a hospitalized setting, specifically for childrenPg. 9
  10. 10. (9). In 2007, a prospective observational multi-centre study was conducted in 44 Dutchhospitals for three days, and tested the value and feasibility of the tool (9). The purpose ofSTRONGkids was to develop an easy-to-use nutritional risk screening tool that will raiseawareness of nutritional risks (9). It consists of four areas: subjective global assessment,high risk disease, nutritional intake and losses, and weight loss or poor weight increase (9).The tool was used upon admission to the hospital in combination with a clinical view of thechilds status and the subjects had their age, sex, diagnosis, and length of stay recorded (9).In addition, all patients had to be greater than one month of age and had to be admitted to thepediatric ward (9). Of the 44 hospitals that participated, STRONGkids was used in 98% of thechildren admitted to the hospital, and it predicted 54% were at moderate risk, 8% were at highrisk of developing malnutrition (9). The current method used is the weight for heightmeasurements which only predicted 19% of children admitted were at risk for malnutrition (9).The study concluded, STRONGkids is an effective nutritional risk screening tool and will raiseawareness of the importance of nutritional status in children (9). Also, this tool can ensureearly identification of children at nutritional risk which will than ensure nutritional interventionsthat can help with overall improvement in patient care (9). In 2009, a study titled, “Decreasing Trends in Malnutrition Prevalence Rates Explainedby Regular Audits and Feedback,” was published (10). The article states that the prevalencerates for malnourished patients in European healthcare organizations range from 10 to 60%(10). As a result of this high prevalence rate, billions of Euros are spent each year sincemalnutrition leads to increased mortality, longer hospital stays, decreased quality of life, andincreased complication rates (10). The study analyzed the trend of malnutrition prevalencerates between 2004 and 2007 and reviewed the effects of the previous audits and feedbackPg. 10
  11. 11. from the Dutch National Prevalence Measurement of Care Problems (LPZ); in addition, theparticipation in the Dutch national improvement programs were also reviewed (10). For 3consecutive years, a standardized questionnaire that involved measurements at institutional,ward, and patient levels were given; and nutritional status was assessed through BMI,unplanned weight loss, and nutritional intake (10). Recently, more attention and awarenesshas been shown toward malnutrition in Dutch healthcare organizations and has triggered 2national government-sponsored improvement programs (10). The program designed forhospitals was launched in 2006 and is called “Eat Well to Get Well.” The aim for this programis to improve the attitudes toward nutritional screening and provide excellent nutritionaltreatment for patients (10). The other program, which was designed for nursing homes andresidential homes, was also started in 2006 and is called “Care for Better,” which focuses onnutritional screening, a weighing policy, and improving the environment where mealtime takesplace (10). The results showed that 269 organizations (80 hospitals, 141 nursing homes, and48 home care organizations) were reviewed and 74,496 observations were made (10).Furthermore, 6 hospitals and 12 nursing homes were involved in the Dutch national qualityimprovement programs (10). The study shows that involvement in a national improvementprogram significantly reduced the prevalence rates of malnutrition in a hospital and homecare setting, but did not show improvement in nursing homes (10). An article from the Ghana Medical Journal titled, “Malnutrition: Missed Opportunities forDiagnosis,” studied the prevalence of wasting among children who were greater than threeyears old and younger than five years old (11). This specific age group needs adequatenutrition from macronutrients and micronutrients since the body has a high demand to ensureoptimal growth and development (11). An imbalance of nutrients whether it be inadequatePg. 11
  12. 12. intake or over consumption of nutrients can lead to stunting of growth (inadequate intake),overweight, obesity, or chronic diseases such as type 2 diabetes mellitus (over consumption)(11). Globally, 9% of children are malnourished and 54% of deaths for children under the ageof five occur because of malnutrition (11). In Ghana, growth assessments are typically doneat child welfare clinics, but usually parents will not visit these clinics after the completion oftheir childrens vaccination at 9 month of age, resulting in widespread cases of malnourishedchildren (11). Three commonly used anthropometric measurements in children are weight-for-height, height-for-age, and weight-for-age which are used in the assessment of nutritionalstatus and diagnosis for malnutrition (11). However, Ghana does not routinely take thesemeasurements in most clinics and hospitals, or like as stated in previous text, the parentsdiscontinue attending the clinics (11). As a result, malnutrition is often not detected andchildren are not able to have an accurate nutritional assessment (11). In 2004, between thesummer months of June and August, the children who went to the outpatient clinic at KomfoAnokye Teaching Hospital were assessed using the weight for height measurement (11). Outof 1182 children involved in the study, 638 were male and 444 were females, the mean agewas 24.9 months, the mean weight was 10.5 kg, and the mean height was 83.4 cm (11). Theresults showed that 251 children out of 1182 children were considered wasted, 48 of thechildren were severely wasted, and the overall prevalence of wasting in this study was 21.2%(11). One out of every 5 children in Ghana are considered malnourished and this problem isa common occurrence in developing countries (11). The United Nations Childrens Fund(UNICEF) reports that in developing countries, 27% of children under the age of 5, suffer fromwasting (11). The mortality rate in Ghana shows that 40% of mortality in children under theage of 5 are due to malnutrition and the rate is increasing over time due to a decliningnutritional status (11).Pg. 12
  13. 13. In 2001, an article titled, “Simple nutrition screening tools for healthcare facilities:development and validity assessment,” was published (12). The study recognized thatdietitians cannot always carry out screening in health care facilities, and often times thisresponsibility is given to the nursing staff upon admission of the patients (12). Nutritionscreening tools are used to identify individuals who are at high nutritional risk (12). In orderfor the proper data to be obtained in the screenings the tools need to be simple and based oninformation collected from the nursing admission questionnaire (12). The purpose of thestudy was to develop and asses timely and valid tools for screening for protein-energymalnutrition (PEM) (12). One hundred and sixty subjects were recruited for this study, fromtwo settings, and a dietetic technician administered the initial screening tool, which was madeup of 9 PEM risk factors (12). The subjects included 54 adults in an acute care setting, 57elderly adults in an acute care setting, and 49 adults in a long term care setting (12). Todetermine the validity of the screening tool Registered Dietitians completed comprehensivenutritional assessments (12). The study consisted of two tools, the first tool used body massindex (BMI) and percentage of weight loss along with classifying subject as having a high orlow PEM risk level; and the second tool utilized BMI and albumin levels ( which were availableupon admission) (12). The tools had a 75.9% or higher validity rating, except for adults in anacute care setting (results were lower) (12). Overall, both tools proved to be helpful forRegistered Dietitians in establishing their priorities for involvement and initiating patient care(11). Focusing on the future of Dietetics and Nutrition, the article titled, “ Adult starvation anddisease-related malnutrition: A proposal for etiology-based diagnosis in the clinical practicePg. 13
  14. 14. setting from the International Consensus Guideline Committee,” stated multiple definitions formalnutrition exist in literature, which can result in confusion; and their purpose was to definemalnutrition in adults in a clinical setting (13). An International Guideline Committee wasdeveloped (no reported conflicts of interest were reported) and consensus for the definitionswas achieved through a series of meetings held at ASPEN and ESPEN Congresses (13).The article states that malnutrition can cause adverse side effects on clinical outcomes, andalso is measurable (13). In a clinical setting, inadequate intake in adults can be seen inpatients with medical conditions such as anorexia nervosa, in which the patient has chronicstarvation without inflammation (13). Additionally, mild or moderate inflammation is seen inchronic conditions such as organ failure, pancreatic cancer, rheumatoid arthritis, orsarcopenic obesity (13). Finally, inflammation can be seen in acute disease or injury stresssuch as major infection, burns, trauma, or closed head injury (13). In a clinical practicesetting, disease related malnutrition is commonly seen, and currently there is no clearconsensus of how malnutrition should be defined (13). This commentary proposes a updatedand simple approach based upon etiology that incorporates the degrees of inflammation inconjunction with malnutrition (13). Since malnutrition is often associated with inflammationthe International Guideline Committee proposed the following etiologies (13):•Chronic starvation (ex. anorexia nervosa) without inflammation could be termed “starvation-related malnutrition (13).”•Chronic conditions (ex. organ failure, pancreatic cancer, rheumatoid arthritis, or sarcopenicobesity) with mild or moderate inflammation could be termed “chronic disease-relatedmalnutrition (13).”•Acute conditions (ex. major infection, burns, trauma, or closed head injury) with severePg. 14
  15. 15. inflammation can be termed “acute disease or injury-related malnutrition (13).” Internationally, malnutrition in the hospital is all too often untreated and underdiagnosedwhich leads to increased cost to individuals, health care and social services, and even society(14). Malnutrition is commonly seen in the elderly population; however, the majority of peopleat risk are below the age of 65 years old (14). Socioeconomic factors (income levels, socialisolation, and substance abuse) play a role in malnutrition, and its prevalence is often found inareas of low economic status (14). The hospital should be an institution where patients whoare malnourished upon admittance can be treated and educated on how obtain low cost foodor assistance through sources in the community through government services (14). Thefuture of malnutrition seems to have an increasing trend in the number of patients that willsuffer from the condition (14). Patterns effecting this trend are increases in the agingpopulation, increases in self-care instead of hospital care, shifts in the pattern of fooddistribution, and an increase in conditions associated such as dementia, oral problems, andstroke (14). Awareness is a starting point in the prevention of malnutrition, and members ofthe multidisciplinary team need to be educated on what to look for (14). One strategy wouldbe to start by educating undergraduate and post graduates in the medical field on the topicand educate them with nutritional care forms that can be used to determine malnutrition (14).In addition, those who are currently apart of the multidisciplinary team should be trained andequipped with the necessary tools needed to combat malnutrition (14). Also, continuingprofessional requirements in this topic area should be mandatory (14). Malnutritionis preventable and treatable. Awareness, prevention, and intervention need to be initiated inthe local community, in clinical settings, and throughout the nation.Pg. 15
  16. 16. References:1.Available at: Accessed March30, 2010.2.Hiesmayr M et al. Decreased food intake is a risk factor for mortality in hospitalised patients:The NutritionDay survey 2006. European Society for Clinical Nutrition and Metabolism. 2009;28: 484-491.3.Patel M et al. (2008). Why Dont Elderly Hospital Inpatients Eat Adequately? BNET.Available at: . AccessedMarch 30, 2010.4.Ney D et al. Senescent Swallowing: Impact, Strategies, and Interventions. Nutr Clin Pract.2009; 24; 395.5.Barron M, Pencharz P. Nutritional Issues in Infants With Cancer. Pediatr Blood Cancer.2007; 49: 1093-1096.6.Gariballa S. Refeeding syndrome: A potentially fatal condition but remains underdiagnosedand undertreated. Nutrition. 2008; 24: 604-606.7.Willis T et al. (2004). Refeeding Syndrome in a Severely Malnourished Child: Discussion.Medscape Today. Available at: . AccessedMarch 30, 2010.8.Capo-chichi C et al. Concentrations of riboflavin and related organic acids in children with protein-energy malnutrition. Am J Clin Nutr. 2000; 71: 978-986.9.Hulst J. Dutch national survey to test the STRONGkids nutritional risk screening tool inhospitalized children. European Society for Clinical Nutrition and Metabolism. 2010; 29:106-111.10.Meijers J et al. Decreasing Trends in Malnutrition Prevalence Rates Explained by RegularPg. 16
  17. 17. Audits and Feedback. The Journal of Nutrition. 2009; 139,7: 1381-1386.11.Antwi S. Malnutrition: Missed Opportunities for Diagnosis. Ghana Medical Journal. 2008;42: 101-104.12.Laprote M et al. (2001). Simple nutrition screening toolsfor healthcare facilities:development and valididty assessment. PubMed. Available at: . Accessed March 30, 2010.13.Jensen G et al. Adult starvation and disease-related malnutrition: A proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus GuidelineCommittee. Clinical Nutrition. 2010; 29: 151-153.14.Availabe at: . AccessedMarch 30, 2010.Pg. 17
  18. 18. Pg. 18