Malnutrition is a severe complication among patients with inflammatory bowel disease (IBD) and cannot be defined by single markers, Kelly Issokson, RD, said in her presentation on assessing malnutrition among hospitalized patients with IBD at the 2022 Crohn’s & Colitis Congress on January 22.

Issokson is a registered dietician with the Nutrition and Integrative IBD Program at Cedars Sinai Medical Center in Los Angeles, California.

Issokson explained that a nationwide study found that hospitalized patients with IBD were 5.5 times more likely to have malnutrition than hospitalized patients without IBD. And according to previous studies, up to 85% of inpatients with IBD may be malnourished. Issokson also pointed out that it is difficult to understand the actual rate and prevalence of malnutrition in IBD because of a lack of a consensus on the criteria to diagnose malnutrition.

“Because inflammation is catabolic and anorexigenic,” Issokson explained, “it really does prime our patients for nutrition derangement.” The severity of malnutrition is influenced by disease activity, duration, and extent of IBD. There are many factors that can lead to malnutrition in IBD, such as malabsorption, enteric losses, inadequate intake, and the effects of medical therapy. In turn, malnutrition is an independent risk factor for venous thromboembolism, nonelective surgery, longer hospital stays, and increased mortality in this population. It can also lead to a reduced response to pharmacotherapy, an increased risk for infection and sepsis, perioperative complications, and increased costs.

Issokson stressed that malnutrition cannot be defined by single markers in a patient. Low albumin, low prealbumin, weight, or BMI alone should not be used to assess a patient’s nutritional status. She offered the American Society for Parenteral and Enteral Nutrition (ASPEN) definition of malnutrition instead: “an acute or chronic state of overnutrition or undernutrition with or without inflammatory activity that has led to a change in body composition and diminished function.”

The first step in diagnosing a patient for malnutrition is nutrition screening, which is “the process of identifying individuals who may be at nutrition risk and may benefit from assessment from a registered dietitian.” This screening is required by the Joint Commission. Patients at a high risk for malnutrition are those who have experienced unintentional weight loss, have had decreased appetite or intake, are restricting multiple foods, and show signs of wasting.

While there is currently no validated screening tool for hospitalized patients with IBD, the Malnutrition Screening Tool (MST), which consists of only 2 yes-or-no questions, is recommended by the Academy of Nutrition and Dietetics (AND), to screen all adults for nutrition, regardless of patient age, history, or setting. If a patient is found to be at nutrition risk, Issokson said, they should be referred for further assessment by dietician.

In IBD, there are several factors that can go into a nutrition assessment: anthropometrics, biochemical markers, symptoms, and body composition. Issokson pointed out that, when looking at BMI, clinicians should be aware “that there are patients with normal BMI that may have altered body composition.” Because 60% of patients with IBD have decreased muscle mass, it is “important to use validated tools to assess their body composition” such as hand-grip strength and bioelectrical impedance analysis. In terms of biochemical markers, there is currently a lack of evidence to support the monitoring of any specific nutrients, but common biochemical markers than can be considered are vitamin D, vitamin B6, vitamin B12, and iron, which are commonly low in patients with IBD.

Other factors to consider are nutrition intake, diet history and eating behaviors, allergies or intolerances, cultural or religious food preferences, food security and accessibility, food-nutrient interactions from any medications, supplement use, and the medical/surgical history of the patient. A Nutrition Focused Physical Exam (NFPE) can also be conducted by a registered dietician, which includes noting skin manifestations of malnutrition or malabsorption, fat stores, muscle mass, and fluid status.

While there are currently no universally accepted criteria for diagnosing malnutrition, AND and ASPEN together have developed criteria for physicians to use, as well as the European Society for Parenteral and Enteral Nutrition (ESPEN)/ Global Leadership Initiative on Malnutrition (GLIM) criteria.

The AND/ASPEN Malnutrition Criteria includes 6 factors: weight loss, energy intake, subcutaneous fat loss, subcutaneous muscle loss, general or local fluid accumulation, and hand grip strength. If a patient meets 2 of the 6 criteria they may be diagnosed with malnutrition. The ESPEN/GLIM Criteria uses 3 phenotypic criteria (weight loss, BMI, and muscle mass) and 2 etiologic criteria (reduced food intake/assimilation and inflammation). A patient needs to meet one of each to be considered malnourished. Issokson also stated that there is a need for “validation studies for using these criteria in [the IBD] population.”

“When identified, please document malnutrition and…intervene appropriately,” Issokson advised, “by referring to a dietician, providing education, and supporting your patients to help them optimize their nutrition and improve their outcomes.”

—Allison Casey

Reference:
Issokson K. Inpatient malnutrition: Define, identify, assess. Presented at: Crohn’s & Colitis Congress. January 22, 2022. Virtual.