COM 5005 Lecture 6: Nutrition Screening, Assessment, and Malnutrition PDF

COM 5005 Lecture 6: Nutrition Screening, Assessment, and Malnutrition Stephanie N. Petrosky, D.C.N., M.H.A., RDN, FAND Associate Professor and Chair, Department of Nutrition Dr. Kiran C. Patel College of Osteopathic Medicine January 24, 2025, 8:10 – 9:00 am  Learning Objectives Lec...

COM 5005 Lecture 6: Nutrition Screening, Assessment, and Malnutrition Stephanie N. Petrosky, D.C.N., M.H.A., RDN, FAND Associate Professor and Chair, Department of Nutrition Dr. Kiran C. Patel College of Osteopathic Medicine January 24, 2025, 8:10 – 9:00 am  Learning Objectives Lecture 6 1. Recall health trends in the nutritional status of all people living in the United States 2. List nutrition screening tools used in various settings 3. Define the Nutrition Care Process 4. Identify the components of nutritional assessment 5. Define malnutrition and differentiate between the various classifications Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 2  Session Outline Nutrition screening 1. Identifying nutritional risk 2. Nutrition risk factors 3. Screening tools and resources for practice Nutrition assessment 1. Components of nutritional assessment 2. Physical exam and hallmark findings 3. Assessment tools and resources for practice Nutrition diagnosis 1. Forms of malnutrition 2. Classification and communication about malnutrition 3. Applications in patient care 3  Why Does Nutrition Matter? Find the case with nutritional risk. Α Β C 56 yo labor worker 16 yo soccer player 70 yo accountant Moderate activity 56 yocompetitor labor worker Elite Limited activity Hx: diabetes, HTN Moderate activity No PMH; vegan Hx: smoker BMI: 28 Hx: diabetes, HTN BMI 18 BMI: 24 BMI: 28 4  Why Does Nutrition Matter? Findings: Systematic analysis, examined 333 causes and 84 risk factors Health in the United States improved from 1990 to 2016 Drivers of mortality and morbidity have changed in some states, with specific risk factors such as drug use disorders, high body mass index (BMI), and alcohol use disorders being associated with adverse outcomes. In 5 states, the probability of death between ages 20 and 55 years has increased more than 10% between 1990 and 2016. The US Burden of Disease Collaborators. The State of US Health, 1990-2016: Burden of Diseases, Injuries, and Risk Factors Among US States. JAMA. 2018;319(14):1444–1472. Lecture 6 COM 5005 Winter 2025 NSU KPCOM – Department of Nutrition 5 NSU KPCOM – Department of Nutrition 6  Health Trends The U.S. spent $4,255.1 billion on health care in 2021. Where did it go? Rama A. American Medical Association. 2021. Trends in Health Care Spending. https://www.ama- assn.org/about/research/trends-health-care-spending 7  Health Trends Source: 2022 Global Nutrition Report. Country Reports. United States of American. https://globalnutritionreport.org/resources/nutrition- profiles/north-america/northern-america/united-states-america/#overview 8  A reprint of the original 1974 editorial article in which physicians were alarmed over the frequency with which hospital patients were being malnourished (iatrogenic nutrition). Dr. Butterworth first brought to light undesirable practices that adversely affect the nutritional health of patients. Photo Credit: https://www.turbosquid.com/3d-models/human-female-skeleton-pose-max/1025026 Source: Butterworth CE. The skeleton in the hospital closet. Nutrition Today. 2015;(2):98. 9  Economic Impact of Malnutrition Average cost = nearly $17,000 per patient for readmission following hospitalization 2.2 million hospital stays involve malnutrition Malnourished patients have 2x hospital costs and 3x death rate Common conditions = infection, pneumonia and congestive heart failure Goates S, et al. PLoS ONE. 2016;11(9):e0161833 Barrett ML, Bailey MK, Owens PL. Online 2018. U.S. Agency for Healthcare Research and Quality. Image Source: Defeat Malnutrition Today  Terminology in Nutritional Care Nutrition Status: State of the body related to consumption and utilization of nutrients. üReflects nutrient stores üExcess or deficient nutrient intake üConsiders individual needs, utilization, and demand Nutrition Screening: The steps toward the risk identification of patients, clients, or groups who may have a nutrition diagnosis and benefit from nutrition assessment and intervention Nutrition Assessment: A systematic process of obtaining, verifying, and interpreting data to make decisions about the nature and cause of nutrition- related problems. Lacey and Pritchett JADA 2003;103:1061-1072 Understanding the pathophysiology, treatment, and clinical course of a disease or diagnosis allows one to identify nutrition problems. Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 11  Nutrition Risk Factors Age: elderly and children Altered nutrition needs: pregnancy, lactation, adolescents Socioeconomic factors Unintended weight loss > 10% in 6 months 85% usual body weight Impaired nutrient digestion, absorption, utilization Altered metabolic conditions: critical illness, cancer, diabetes Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 12  Nutrition Care Process Describe the problem Evaluate nutrition indicators Standard terminology Physical exam Intake history Nutrition Nutrition Assessment Diagnosis Nutrition Screening Monitoring and Intervention Evaluation Individual care plans Counseling Check understanding Nutrition education Measure outcomes Reassessment Definition: The Nutrition Care Process (NCP) is a systematic approach to providing high quality nutrition care. The NCP consists of four distinct, interrelated steps. Academy of Nutrition and Dietetics  Nutrition Care Algorithm Source: American Society for Enteral and Parenteral Nutrition Uklejia et al. Nutr Clin Pract. 2010;25(4):403-414. Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 14  Nutrition Screening Tools Malnutrition Universal Screening Tool (MUST) üAdults and community setting; predicts mortality Nutrition Risk Screening (NRS-2000) üAcute adult; retrospective factors DETERMINE Checklist üNon-institutionalized older adults; used by Older Americans Act programs Mini Nutrition Assessment (MNA) üMost validated (specific and sensitive) in older adults to identify true risk üBasic applications, all settings, fast and easy Subjective Global Assessment (SGA) üComprehensive with medical and functional Hx; many health care settings Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 15 Sample Tool: Mini Nutrition Assessment 16  Sample Tool: Subjective Global Assessment Image Source: https://nutritioncareincanada.ca/resources-and-tools/hospital-care-inpac/assessment-sga  Nutrition Assessment: Overview Provides the foundation for the nutrition care process Systematic method for obtaining, verifying, and interpreting data Identifies nutrition-related problems, causes, and significance Data collection, considering: üDietary intake üNutrition-related consequences of health and disease condition üPsycho-social, functional, and behavioral factors üKnowledge, readiness, and potential for change Compare findings to relevant standards Identify possible problem areas Organize data to relate to nutrition problems Determine when problems require referral Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 18  Assessment: Key Components 1. Patient History 2. Anthropometrics 3. Biochemical Data 4. Clinical/Nutrition-Focused Physical Exam 5. Functional Assessment Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 19  1. Patient History: Data Collection Dietary history: Recall or food frequency Review of medical records and medical histories Family history, age, gender, education level, food security, and socioeconomic data Clinical findings: medical tests and procedures Previous medical history and testing that impact nutritional status Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 20  Sample Tool: Food/Nutrition-Related History Category of Problem Specific Examples from Patient History Food and nutrient intake Mother reporting her child’s food intake for previous 24 hours Medication and complementary or Patient reporting current medications and use of herbal supplements alternative medicine use Knowledge/beliefs/attitudes Patient stating that he avoids “sweets and desserts” as his diet modification for diabetes Behavior Patient decides that she will eat only while sitting at kitchen table with family members as a step to decrease snacking behaviors Factors affecting access to food and Patient reports that he has access to a microwave but does not have a food/nutrition-related supplies stove or oven Physical activity and function Patient states that she is unable to walk up more than one flight of stairs Nutrition-related patient-centered Patient voices that she sees no benefit to improving blood glucose measures levels: “I have tried different diets, and I don’t think it will make any difference for my diabetes if I change my diet”  Sample Tool: Twenty-Four-Hour Recall Patient is guided to recall all food and drink in the previous 24-hour period Variation of this method is the USDA multiple pass Advantage ⁃ Short administration time, very little cost, and negligible risk for the client Disadvantage ⁃ May not always reflect typical eating patterns Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 22  Sample Tool: Food Record/Food Diary Patient records all dietary intake for a specified time Advantage ⁃ Does not rest on memory and is more representative of typical eating patterns Disadvantage ⁃ Validity issues arise if patient alters or misrepresents intake ⁃ Heavier burden Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 23  2. Anthropometrics Nutrition care indicator: Height/stature/length ⁃ For age 2: Standing height is measured using a tape measure or stadiometer ⁃ Alternatives: Arm span and knee height methods Nutrition care indicator: Weight ⁃ Balance beam and electronic scales ⁃ Wheelchair and bed scales ⁃ Amputation calculations are made based on some factors for people with an amputation - Adjusted body weight Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 24  Anthropometrics: Comparisons Evaluation and interpretation of Evaluation of height, weight, and height and weight head circumference Usual body weight üGrowth charts: Compare to a Percent usual body weight reference population and percent weight change Weight for height Reference weights Percentile weight Head circumference Body mass index (BMI) üBody mass index (BMI) Waist circumference Overweight falls in 85th - 95th percentile of BMI for age Obese is defined as > 95th percentile of BMI for age Underweight is < 5th percentile Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 25  Sample Tool: CDC Growth Charts Lecture 6 COM 5005 Winter 2025 Sample Tool: CDC Growth Charts (BMI) Source: https://www.cdc.gov/growthcharts/Extended-BMI-Charts.html 27  Anthropometrics: Body Composition Body composition: Distribution and size of all components contributing to total body weight ⁃ Refers to fat mass and fat-free mass ⁃ Waist circumference and hip-to-waist ratio ⁃ Fat mass, body water, osseous mineral, and protein stores ⁃ Primary concern is about metabolically active tissue and fluid status Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 28  Anthropometrics: Skinfold Measurement Estimates energy reserves in subcutaneous tissue Advantages üMinimally invasive and requires minimal equipment Disadvantage üTakes significant amount of repetition and experience to Source: SR Rolfes, K Pinna & E Whitney, Understanding Normal and Clinical Nutrition 7e, Fig E7, p E8. obtain consistent, reliable results with training Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 29 Anthropometrics: Skinfold Measurement Interpretation and evaluation of skinfold measurements ⁃ Individual who is < 5th percentile or > 95th percentile may be at nutritional risk Multiple-site skinfold measurements can be used to estimate body density and body fat percentage Percentile Arm Muscle Area Arm Fat Area Total Body Weight Rank 85 Above-average Excess fat Excess total body musculature weight Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 30  Anthropometrics: Bioelectrical Impedance Analysis (BIA) Source: Courtesy of Marcia Nelms. BIA not appropriate for patients who have experienced major shift in water balance and distribution Phase angle: (Direct measure of cellular integirty) is used as an additional measure of prognosis in many chronic conditions  Anthropometrics: InBody Scanner More user friendly Outpatient and ambulatory settings Health and fitness coaching Fairly consistent measures with other BIA devices Data print-off / tracking Source: Courtesy of Marcia Nelms.  3. Biochemical Medical Tests and Procedures Measurement of nutritional markers and indicators found in blood, urine, feces, and tissue samples ⁃ Routine laboratory measures – general health markers ⁃ Hematological ⁃ Protein assessment ⁃ Immunocompetence ⁃ Presence of inflammation ⁃ Vitamin and mineral assessment Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 33  Biochemical Indicators Chem—7 panel ⁃ BUN (blood urea nitrogen), serum chloride, CO2 (carbon dioxide), creatinine, glucose, serum potassium, and serum sodium Chem—20 panel ⁃ Albumin, alkaline phosphatase, ALT (alanine transaminase), AST (aspartate aminotransferase), BUN (blood urea nitrogen), serum calcium, serum chloride, CO2 (carbon dioxide), creatinine, direct bilirubin, gamma-GT (gamma-glutamyl transpeptidase), glucose, LDH (lactate dehydrogenase), serum phosphorus, potassium test, serum sodium, total bilirubin, total cholesterol, total protein, and uric acid Immunocompetence ⁃ Protein deficiency routinely results in increased risk of infection as well as altered immune and inflammatory responses ⁃ Total lymphocyte count (TLC) equals WBC multiplied by percent lymphocytes, whole divided by 100 34  Biochemical: Hematological Indicators Hemoglobin (Hgb) Hematocrit (Hct) Mean corpuscular volume (MCV) Mean corpuscular hemoglobin (MCH) Mean corpuscular hemoglobin concentration (MCHC) Ferritin, transferrin saturation, and protoporphyrin Serum folate and serum B12 Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 35  Biochemical: Visceral Protein Status Visceral protein assessment: Non-skeletal proteins ⁃ Albumin ⁃ Transferrin ⁃ Prealbumin or transthyretin ⁃ Retinol-binding protein (RBP) ⁃ C-reactive protein (CRP) - check for inflammation Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 36  Biochemical: Somatic Protein Status Nutrition care indicator: Creatinine height index ⁃ Correlates daily urine output of creatinine with height Nutrition care criteria: Interpretation and evaluation of creatinine height index ⁃ Uses ratio of 24-hour urine creatinine output to expected output Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 37  Biochemical: Micronutrient Status Laboratory tests are available for the assessment of most vitamins and minerals ⁃ High-performance liquid chromatography ⁃ Antibody tests ⁃ Microbiological, radioisotopic, and chemiluminescence assays Common situations when vitamins are routinely measured: ⁃ Serum vitamin D assessment in inflammatory bowel disease, osteoporosis, and renal disease ⁃ Thiamin levels for individuals who are on long-term diuretics or alcohol ⁃ B12 assessment for individuals with GI diseases or vegan lifestyle Refer to the posted review article in Canvas – Assessment of Micronutrient Status Holler, Bakker, Dusterloh et al. 2018 Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 38 4. Clinical/Nutrition Focused Physical Examination (NFPE) Systematic head-to-toe examination of a patient's physical appearance and function to help determine nutritional status by uncovering any signs of malnutrition, nutrient deficiencies, or nutrient toxicities Consensus statement (2012), the Academy of Nutrition and Dietetics (the Academy) and the American Society for Parenteral and Enteral Nutrition (ASPEN) defined malnutrition as the presence of two or more of the following characteristics: – insufficient energy intake – weight loss – loss of muscle mass – loss of subcutaneous fat – localized or generalized fluid accumulation – decreased functional status Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 39  Facial Features Actor: Patrick Swayze circa 1987 and 2008 40 Nutrition-Focused Physical Examination Fat loss - hollows, depressions, or loose skin around the eyes Source: Malnutrition Quality Improvement (Mqii) Lecture 6 COM 5005 Winter 2025 NSU KPCOM – Department of Nutrition 41 Nutrition-Focused Physical Examination Muscle loss - a depression or pit at the temples Source: Malnutrition Quality Improvement (Mqii) Lecture 6 COM 5005 Winter 2025 NSU KPCOM – Department of Nutrition 42  Nutrition-Focused Physical Examination Muscle and fat loss - prominent clavicle bones or sharply squared-off, bony shoulders Source: Malnutrition Quality Improvement (Mqii) Lecture 6 COM 5005 Winter 2025 NSU KPCOM – Department of Nutrition 43 Photo Credit: Washington Free Beacon Actor Christian Bale – The Machinist 44  Nutrition-Focused Physical Examination Fat loss at the triceps - fingers meet when the skin is pinched and mid-arm circumference measure Source: Malnutrition Quality Improvement (Mqii) Lecture 6 COM 5005 Winter 2025 NSU KPCOM – Department of Nutrition 45 Nutrition-Focused Physical Examination A depression instead of a bulge in the interosseous muscle (between the thumb and forefinger on the back of the hand) when the patient presses their thumb and forefinger together Source: Malnutrition Quality Improvement (Mqii) Lecture 6 COM 5005 Winter 2025 NSU KPCOM – Department of Nutrition 46 Nutrition-Focused Physical Examination Physical signs that may indicate dehydration (decreased skin turgor) or overhydration (edema) Source: Malnutrition Quality Improvement (Mqii) Lecture 6 COM 5005 Winter 2025 NSU KPCOM – Department of Nutrition 47  Skin Technique: Inspection and palpation Inspect: Color and uniform appearance, thickness, symmetry, hygiene, and presence of lesions, tears, bruising, edema, rashes, or flakiness. Palpate: moisture, temperature, texture, turgor, and mobility Possible Diagnoses: Dehydration, edema, infection Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 48  Head Technique: Inspection and palpation Inspect: Eyes Palpate: Patient’s hair Possible Diagnoses: Hypothyroidism, hyperthyroidism, protein deficiency, dehydration, vitamin A deficiency, biotin deficiency Hyperthyroidism Biotin Deficiency Bitot Spots Lecture 6 COM 5005 Winter 2025 49  Oral Health Technique: Inspection Inspect: Tongue, color and surface of lips, corners of the mouth, mucosa, gums, palate, and teeth/dentures. Determine if there is pain when chewing or swallowing. Possible Diagnoses: Dehydration, riboflavin deficiency, anemia, vitamin C deficiency, niacin deficiency, B-12 deficiency Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 50  5. Functional Assessment Hand grip – voluntary muscle strength 30-second chair stand – endurance, leg strength Timed up and go test – balance, endurance Activities of Daily Living (ADLs) – older adults Karnofsky Performance Scale Index – correlates with role of sarcopenia Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 51  Causes of Malnutrition Definition of Malnutrition (ASPEN): An acute, sub-acute or chronic state of nutrition, in which a combination of varying degrees of overnutrition or undernutrition with or without inflammatory activity have led to a change in body composition and diminished function. (adapted from Soeters PB, Schols AM. Advances in understanding and assessing malnutrition) Primary - Frank inadequate nutrient intake – Intake < needs with no underlying or concurrent pathology – Ex: Self-restrictive eating pattern; socioeconomic influence; global issues from war, famine, or political demise Secondary – Result of contributing factors that alter status – Malabsorption – Impaired utilization or storage Examples on next slide – Excessive nutrient losses – Increased nutrient needs Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 52  Secondary Causes of Malnutrition Contributing Factors - Examples Malabsorption – Malabsorption syndromes (Chron’s disease, Cystic Fibrosis) – Genetic diseases (Hereditary folate malabsorption) Impaired Utilization or Storage – Medications and nutrient interactions – Gastric bypass and loss of intrinsic factor (IF) for B12 absorption Excessive Nutrient Losses – Ostomies – Chronic alcoholism (folate excretion) Increased Nutrient Needs – Infections, trauma, hypercatabolic states – Teen male in puberty Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 53  Compare Perspectives: Medical versus Nutritional Dx Medical Diagnosis Nutritional Diagnosis: Problem, etiology, signs/symptoms Diabetes Excessive CHO intake r/t lack of nutrition education as evidenced by diet hx and high hs blood glucose Trauma with closed head Increased energy needs r/t multiple trauma as evidenced by injury results of indirect calorimetry Obesity Altered nutrient utilization r/t lack of access to healthy food choices as evidenced by diet history and BMI of 35. Dependence on Excessive energy intake r/t high volume parenteral nutrition as mechanical ventilation evidenced by RQ >1 Anorexia nervosa Self-monitoring deficit r/t history of anorexia nervosa as evidenced by diet history and recent weight loss of 5 lb/2 wk Etiology-Based Malnutrition Definitions Source: Tappendan KA, Quatrara B, et al. MEDSURG Nursing. May–June 2013; 22(3): 147–165. Image Source: Nelms, Sucher, and Lacey  Source: Malnutrition Quality Improvement Initiative Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 56 Sample Tool: Global Leadership Initiative on Malnutrition (GLIM) 2019 Cederholm T, Jensen GL, Correia MITD, et al. Clin Nutr. 2019;38(1):1-9. 57 Sample Tool: Global Leadership Initiative on Malnutrition (GLIM) 2019 Malnutrition (moderate or severe) is confirmed when at least 1 criterion in each section is checked 58  Classic Malnutrition: Kwashiorkor Syndrome of severe protein deficiency Dramatic loss of protein Intake ↑ Risk for infections Protuberant belly Edema, fatty liver, hepatomegaly Ascites (Hypoalbuminemia) “Flaky paint”(Skin Lesion) Linear depigmentation of the hair “Flag Sign” Growth failure – most often stunting Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 59  Classic Malnutrition: Marasmus Protein-Calorie Malnutrition (PCM) Somatic muscle wasting, spindly arms Hanging skin, wrinkle face ( “shrunken old person”) ↓body weight, ↓subcutaneous fat Lipofuscin pigment (visceral organs) No edema Serum albumin normal ↓↓ Pulse – BP- Temperature Numerous, recurrent infections Intellectual deficits Growth failure – wasting Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 60  Summary Points Various factors increase the risk of malnutrition and lead to compromised healing and comorbidities in patient care. Nutrition screening is an interprofessional, best practice that should be a priority in all settings. Nutrition assessment is a process that requires: ü Collaboration ü Critical thinking and understanding of the disease process ü Evidence-based practice ü Documentation ü Monitoring and evaluation Malnutrition results from an imbalance between dietary (exogenous) intake and individual needs. Forms of malnutrition encompass a wide spectrum from undernutrition to overnutrition in the total diet or with specific essential nutrients. Standardized classifications should be used to diagnose malnutrition; a medical diagnosis is distinct from a nutritional diagnosis.  Selected References A.S.P.E.N. Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr. 2002;26:144. Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, Jeejeebhoy KN. What is subjective global assessment of nutrition status? J Parenter Enteral Nutr. 1987;11(1):8. Cederholm T, Jensen GL, Correia MITD, et al. GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community. Clin Nutr. 2019;38(1):1-9. doi:10.1016/j.clnu.2018.08.002 FAO, IFAD, UNICEF, WFP and WHO. 2018. The State of Food Security and Nutrition in the World 2018. Nutrition. World Health Organization. https://www.un.org/nutrition/home. Goates S, Du K, Braunschweig CA, Arensberg MB. Economic Burden of Disease-Associated Malnutrition at the State Level. PLoS One. 2016 Sep 21;11(9):e0161833. Makhija S, Baker J. The Subjective Global Assessment: a review of its use in clinical practice. Nutr Clin Pract. 2008 Aug-Sep;23(4):405-9. Soeters PB, Schols AM. Advances in understanding and assessing malnutrition. Curr Opin Clin Nutr Metab Care. 2009; 12(5):487–494. Shifler Bowers K, Francis E, Kraschnewski JL. The dual burden of malnutrition in the United States and the role of non-profit organizations. Prev Med Rep. 2018;12:294–297. Published 2018 Oct 18. doi:10.1016/j.pmedr.2018.10.002. Tappendan KA, Quatrara B, Parkhurst ML, Malone AM, Fanjiang G, Ziegler TR. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. MEDSURG Nursing. May–June 2013; 22(3): 147–165. Ukleja A, Gilbert K, Mogensen KM, et al. Standards for Nutrition Support: Adult Hospitalized Patients. Nutrition in Clinical Practice. 2018;33(6):906. United Nations Children’s Fund (UNICEF), World Health Organization, International Bank for Reconstruction and Development/The World Bank. Levels and trends in child malnutrition: key findings of the 2019 Edition of the Joint Child Malnutrition Estimates. Geneva: World Health Organization; 2019. Accessed via https://www.who.int/nutgrowthdb/jme-2019-key-findings.pdf?ua=1 Weiss AJ, et al. Characteristics of Hospital Stays Involving Malnutrition, 2013. Healthcare Costs and Utilization Project Statistical Brief #210. Lecture 6 COM 5005 Winter 2025 KPCOM - Department of Nutrition 62