Malnutrition in the Hospital

DTC 6714/8/2010

Corrie Cox

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Malnutrition is a condition in which your body is not getting enough nutrients; and is a

result of an inadequate or unbalanced diet, problems with digestion or absorption, and certain

medical 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). Depending

on the severity of the condition, treatment typically consists of replacing lost nutrients, treating

the 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 been

established as an indicator for an increase in complications (2). In addition, poor nutritional

status has also been associated with higher rates of infection, poor wound healing, longer

hospital stays, and even cardiac complications (2). Current interventions such as protected

meal times, more menu items, additional snacks, encouraging patients to eat, and even sip

feedings have been used to prevent weight loss(2), but the best way to prevent malnutrition

is through eating a well balanced diet (1).

In 2009, the European Society for Clinical Nutrition and Metabolism published a

multinational 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 adult

hospitalized patients (2). The main focus of the survey was the effect of food intake and

nutritional factors on death in a hospital setting (2). NutritionDay utilized members of the

interdisciplinary team and patients which filled out three questionnaires to obtain data (2).

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The first questionnaire described the facility where the patient was staying, the second was

the caregiver's view of the patient (age, height, weight, medical condition, comorbidities, and

type of nutritional intake), and the third questionnaire allowed patients to report their food

intake on NutritionDay (2). The outcome assessment following NutritionDay lasted for 30

days to determine the odds ratio for dying (the effect of the amount of the meal eaten on

mortality) (2). Food intakes on NutritionDay showed that less than half of the patients finished

their meals (2). Patients that reported eating less than half of their meals, or nothing at all,

commonly stated the reason was “not being hungry,” “don't like the taste,” “normally eating

less,” “don't 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 ate

less than half of their meals also received artificial nutrition (2). At the end of the study 634

patients (3.9%) died, and the odds ratio for dying increased as the amount of food consumed

on NutritionDay decreased (2). The study concludes that decreased food intake and altered

nutrition status remains to be a problem within European hospitals (2). As a result, patients

are 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 in

patient charts and may even trigger early nutrition intervention (2).

In 2008, The Journal of Nutrition, Health, and Aging published the article titled, “ Why

Don't Elderly Hospital Inpatients Eat Adequately (3)?” The article states that malnutrition is

common 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 the

elderly population occurs in a hospitalized setting, and what are the consequences of poor

intake(3). For the duration of 4 weeks, 100 patients (mean age of 81.7 years) were observed

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twice a week from admission to discharge; and their intake was reported through

observations, 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 was

determined 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). The

results of the study showed that upon admission, 21 patients were malnourished (based on

height and weight below the 10th percentile), 3 patients became malnourished during their

stay at the hospital, and 67% of patients were reported to be eating inadequately (285/425

assessments were made) (3). The most common reasons for inadequate intake during the

earlier part of the patients' hospital stay was the following: acute illness, anorexia, oral

problems, and catering limitations (3). Throughout the duration of the study, the most

common reason for inadequate intake were: confusion, low mood, and dysphagia (3).

Moreover, in comparison to well nourished patients, malnourished patients had a higher

number of oral problems (3).

Ney D et al., published a review titled, “Senescent Swallowing: Impact, Strategies, and

Interventions,” 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 of

skeletal muscle mass and strength (4). Patients will often develop a fear of eating, an

impaired ability to eat, or even anorexia (4). Dysphagia plays an important role on the effects

of a patients nutrition status and if untreated or undiagnosed, it can lead to dehydration or

malnutrition (4). Specifically, dysphagia can lead to an increased risk of protein-energy

malnutrition that often leads to weight loss, muscle breakdown, dehydration, fatigue,

aspiration pneumonia, and an overall decline in the patients ability to function (4). The review

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discussed a recent study that identified dysphagia and the loss of skeletal muscle

mass/strength as a predictive of hospital acquired infections (4). In addition, untreated or

undiagnosed dysphagia, which progressed to protein-energy malnutrition, increased the

morbidity and mortality rates of patients in a clinical setting (4).

Not only is malnutrition a concern in the elderly population, but also in infants and

children. 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 children

and infants, especially since they have limited energy reserves (5). Furthermore, chronic

malnutrition can effect weight gain, growth, daily interactions, and overall quality of life (5).

Undernutrition, which can lead to malnutrition (prolonged slow weight gain compared to

growth), is a concern for infants since the first two years of life consist of rapid weight gain

and 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 effective

intervention for weight gain, if the gut is functioning (5). Each feeding is individualized for

feeding schedules and formulas, and frequent adjustments may need to be made in order to

achieve effective weight gain (5). Typically, patients will eat during the day and feeds will be

supplemental (5). In the case of chemotherapy, which can decrease a patient's appetite, tube

feeds will be increased to make up for the decrease in oral intake (5). If the gut is

nonfunctioning, total parenteral nutrition (TPN) has also been proven to be an effective

intervention for weight gain in children, specifically cancer patients (5). However, adequate

caloric and protein intake must be met, and it is important to calculate the amount of TPN

actually received rather than what was ordered (5). In conclusion, adequate intake is crucial

for growth and development for infants and children, cancer and chemotherapy can cause

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adverse effects on food intake, if intake is inadequate, consider G-tube feedings or TPN as a

supplementation (5).

In 2008, the study titled, “ Refeeding syndrome: A potentially fatal condition but remains

underdiagnosed and undertreated,” discussed two case studies that involved a 70 year old

woman and a 15 year old girl diagnosed with refeeding syndrome (6). Refeeding syndrome

can occur in patients that have kwashiorkor, marasmus, anorexia nervosa, chronic

malnutrition, 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 nutrition

can 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 during

refeeding syndrome (7). Refeeding syndrome usually occurs within the first few days of

refeeding, and clinical features are nonspecific and can be unrecognizable (7). Case 1

involved a 70 year old woman with dysphagia, shortness of breath, lethargy, and ill health for

the the past four months (6). She had lost weight, the amount unknown, and had been

drowsy and breathless four days prior to admission (6). Her clinical examination did not show

any abnormal blood tests, and her cardiovascular, pulmonary, and abdominal examinations

were unremarkable (6). However, she appeared to have decreased respiratory function and a

high 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 successfully

resuscitated (6). Over the next few days she remained drowsy, weak, and had severe muscle

weakness (6). A consultation by the clinical nutrition team was ordered, and she was

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diagnosed with severe malnutrition complicated by refeeding syndrome with

hypophosphatemia, hypocalcemia, and hypokalemia (which led to worsening of her

respiratory function) (6). Her feedings were changed to high-protein, high-fat, and low

carbohydrate and she was given calcium, phosphate, magnesium, and potassium infusion

until her biochemistry values were within normal limits (6). Three days later she was weaned

from the ventilator and transferred out of the ICU (6). Shortly there after she was sent home

on a normal diet plus oral nutrition supplements (6). Case 2 involved a 15 year old girl who

recently had a total colectomy due to severe ulcerative colitis and was admitted to the hospital

with a 10 day history of nausea and vomiting, lower abdominal pain, severe diarrhea, and

poor oral intake which led to a significant amount of weight loss (6). Upon admission, she

weighed 25 kg, 146 cm tall, and her BMI was <11.7 (severely malnourished) (6). Her sodium

level 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 at

high risk for refeeding syndrome(6). The patient was started on IV fluids, potassium

supplements, antibiotics, and a nutrition consult was ordered (6). She was than started on a

low-calorie feeding through an NG tube and the feedings were gradually increased over a 4

day period (6). At the same time she was also given B-vitamin supplements including

thiamine plus other multivitamins and trace elements, and her electrolytes were closely

monitored over the next four days (6). The patients diarrhea ended and her weight increased

by 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 cases

show the importance of considering refeeding sydrome when starting malnourished patient on

enteral or parental nutrition (6). Refeeding syndrome is a potentially fatal condition that

remains underdiagnosed and undertreated, but if recognized can be treated and prevented

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(6).

According to the article, “Concentrations of riboflavin and related organic acids in

children with protein-energy malnutrition,” riboflavin, flavin mononucleotide, and flavin adenin

dinucleotide concentrations have not been studied in depth in relation to malnutrition (8). The

objective of the study was to look into the effects of malnutrition on riboflavin status and

riboflavin's relation with thyroid hormones and concentrations of urinary organic acids (8).

Clinical records, anthropometric data, and plasma nutritional protein concentrations were

observed throughout the duration of the study (8). Vitamin deficiencies associated with

protein-energy malnutrition are Vitamin A,C,D,E, thiamine, and biotin (8). On the other-hand

vitamins B-12 and folate concentrations are usually found to be within normal limits or

elevated during protein-energy malnutrition (8). Sixty malnourished children from the

savannah in Benin and the coast in Togo (both areas located in western Africa) were

examined for the purpose of this study (8). Based on the Wellcome classification, which was

used to determine the types of protein-energy malnutrition; group S had 18 children

diagnosed with kwashiorkor and 12 with marasmus, and group C had 6 children with

kwashiorkor and 24 with marasmus (8). Anthropometric measurements were taken which

included 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 US

National Center for Health Statistics, and overnight fasting blood and urine samples were

obtained the morning after admission of the subjects (8). The data from the control group

came 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 milk

was the main food source for children under the age of 24 months (8). After 24 months of age

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the main food sources in the diet consisted of rice or maize pudding, vegetables, and on

occasion powdered cows milk (8). The concentrations of riboflavin in maize, millet, and cow

milk 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 and

group C had lower averages anthropometric averages when compared (8). As for comparing

group 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 were

significantly more malnourished than the children in group C (8). Low thyroid hormone

concentrations were also reported in both malnourished groups, but group S appeared to

have lower T3 and T4 concentrations; in addition, children in group S and group C reported to

have iodine intake deficiency (8). Plasma nutritional protein concentrations were lower in

malnourished children when compared to the control group, and group S showed more

significant affects than group C (8). Furthermore, in both malnourished groups plasma

inflammatory protein concentrations were higher than in the control group (8). In group S, the

children had lower plasma transferrin, albumin, and FAD, with a higher riboflavin

concentration reported in comparison to the control group (8). In addition, group C did not

have 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 relationship

between riboflavin concentrations, thyroid hormones, and plasma nutritional proteins in

relation to protein-energy malnutrition (8).

Prevention and identification of malnutrition in a clinical setting seems to be the focus

of current studies taking place. A Dutch national survey called STRONGkids was developed

as a nutritional risk screening tool to be used in a hospitalized setting, specifically for children

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(9). In 2007, a prospective observational multi-centre study was conducted in 44 Dutch

hospitals for three days, and tested the value and feasibility of the tool (9). The purpose of

STRONGkids was to develop an easy-to-use nutritional risk screening tool that will raise

awareness 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 the

child's 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 the

pediatric ward (9). Of the 44 hospitals that participated, STRONGkids was used in 98% of the

children admitted to the hospital, and it predicted 54% were at moderate risk, 8% were at high

risk of developing malnutrition (9). The current method used is the weight for height

measurements 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 raise

awareness of the importance of nutritional status in children (9). Also, this tool can ensure

early identification of children at nutritional risk which will than ensure nutritional interventions

that can help with overall improvement in patient care (9).

In 2009, a study titled, “Decreasing Trends in Malnutrition Prevalence Rates Explained

by Regular Audits and Feedback,” was published (10). The article states that the prevalence

rates 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 since

malnutrition leads to increased mortality, longer hospital stays, decreased quality of life, and

increased complication rates (10). The study analyzed the trend of malnutrition prevalence

rates between 2004 and 2007 and reviewed the effects of the previous audits and feedback

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from the Dutch National Prevalence Measurement of Care Problems (LPZ); in addition, the

participation in the Dutch national improvement programs were also reviewed (10). For 3

consecutive 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 awareness

has been shown toward malnutrition in Dutch healthcare organizations and has triggered 2

national government-sponsored improvement programs (10). The program designed for

hospitals was launched in 2006 and is called “Eat Well to Get Well.” The aim for this program

is to improve the attitudes toward nutritional screening and provide excellent nutritional

treatment for patients (10). The other program, which was designed for nursing homes and

residential homes, was also started in 2006 and is called “Care for Better,” which focuses on

nutritional screening, a weighing policy, and improving the environment where mealtime takes

place (10). The results showed that 269 organizations (80 hospitals, 141 nursing homes, and

48 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 quality

improvement programs (10). The study shows that involvement in a national improvement

program significantly reduced the prevalence rates of malnutrition in a hospital and home

care setting, but did not show improvement in nursing homes (10).

An article from the Ghana Medical Journal titled, “Malnutrition: Missed Opportunities for

Diagnosis,” studied the prevalence of wasting among children who were greater than three

years old and younger than five years old (11). This specific age group needs adequate

nutrition from macronutrients and micronutrients since the body has a high demand to ensure

optimal growth and development (11). An imbalance of nutrients whether it be inadequate

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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 age

of five occur because of malnutrition (11). In Ghana, growth assessments are typically done

at child welfare clinics, but usually parents will not visit these clinics after the completion of

their children's vaccination at 9 month of age, resulting in widespread cases of malnourished

children (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 nutritional

status and diagnosis for malnutrition (11). However, Ghana does not routinely take these

measurements in most clinics and hospitals, or like as stated in previous text, the parents

discontinue attending the clinics (11). As a result, malnutrition is often not detected and

children are not able to have an accurate nutritional assessment (11). In 2004, between the

summer months of June and August, the children who went to the outpatient clinic at Komfo

Anokye Teaching Hospital were assessed using the weight for height measurement (11). Out

of 1182 children involved in the study, 638 were male and 444 were females, the mean age

was 24.9 months, the mean weight was 10.5 kg, and the mean height was 83.4 cm (11). The

results showed that 251 children out of 1182 children were considered wasted, 48 of the

children 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 is

a common occurrence in developing countries (11). The United Nations Children's Fund

(UNICEF) reports that in developing countries, 27% of children under the age of 5, suffer from

wasting (11). The mortality rate in Ghana shows that 40% of mortality in children under the

age of 5 are due to malnutrition and the rate is increasing over time due to a declining

nutritional status (11).

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In 2001, an article titled, “Simple nutrition screening tools for healthcare facilities:

development and validity assessment,” was published (12). The study recognized that

dietitians cannot always carry out screening in health care facilities, and often times this

responsibility is given to the nursing staff upon admission of the patients (12). Nutrition

screening tools are used to identify individuals who are at high nutritional risk (12). In order

for the proper data to be obtained in the screenings the tools need to be simple and based on

information collected from the nursing admission questionnaire (12). The purpose of the

study was to develop and asses timely and valid tools for screening for protein-energy

malnutrition (PEM) (12). One hundred and sixty subjects were recruited for this study, from

two settings, and a dietetic technician administered the initial screening tool, which was made

up of 9 PEM risk factors (12). The subjects included 54 adults in an acute care setting, 57

elderly adults in an acute care setting, and 49 adults in a long term care setting (12). To

determine the validity of the screening tool Registered Dietitians completed comprehensive

nutritional assessments (12). The study consisted of two tools, the first tool used body mass

index (BMI) and percentage of weight loss along with classifying subject as having a high or

low PEM risk level; and the second tool utilized BMI and albumin levels ( which were available

upon admission) (12). The tools had a 75.9% or higher validity rating, except for adults in an

acute care setting (results were lower) (12). Overall, both tools proved to be helpful for

Registered 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 and

disease-related malnutrition: A proposal for etiology-based diagnosis in the clinical practice

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setting from the International Consensus Guideline Committee,” stated multiple definitions for

malnutrition exist in literature, which can result in confusion; and their purpose was to define

malnutrition in adults in a clinical setting (13). An International Guideline Committee was

developed (no reported conflicts of interest were reported) and consensus for the definitions

was 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, and

also is measurable (13). In a clinical setting, inadequate intake in adults can be seen in

patients with medical conditions such as anorexia nervosa, in which the patient has chronic

starvation without inflammation (13). Additionally, mild or moderate inflammation is seen in

chronic conditions such as organ failure, pancreatic cancer, rheumatoid arthritis, or

sarcopenic obesity (13). Finally, inflammation can be seen in acute disease or injury stress

such as major infection, burns, trauma, or closed head injury (13). In a clinical practice

setting, disease related malnutrition is commonly seen, and currently there is no clear

consensus of how malnutrition should be defined (13). This commentary proposes a updated

and simple approach based upon etiology that incorporates the degrees of inflammation in

conjunction with malnutrition (13). Since malnutrition is often associated with inflammation

the 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

sarcopenic obesity) with mild or moderate inflammation could be termed “chronic

disease-related malnutrition (13).”

Acute conditions (ex. major infection, burns, trauma, or closed head injury) with severe

inflammation can be termed “acute disease or injury-related malnutrition (13).”

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Internationally, malnutrition in the hospital is all too often untreated and underdiagnosed

which 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 people

at risk are below the age of 65 years old (14). Socioeconomic factors (income levels, social

isolation, and substance abuse) play a role in malnutrition, and its prevalence is often found in

areas of low economic status (14). The hospital should be an institution where patients who

are malnourished upon admittance can be treated and educated on how obtain low cost food

or assistance through sources in the community through government services (14). The

future of malnutrition seems to have an increasing trend in the number of patients that will

suffer from the condition (14). Patterns effecting this trend are increases in the aging

population, increases in self-care instead of hospital care, shifts in the pattern of food

distribution, and an increase in conditions associated such as dementia, oral problems, and

stroke (14). Awareness is a starting point in the prevention of malnutrition, and members of

the multidisciplinary team need to be educated on what to look for (14). One strategy would

be to start by educating undergraduate and post graduates in the medical field on the topic

and 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 and

equipped with the necessary tools needed to combat malnutrition (14). Also, continuing

professional requirements in this topic area should be mandatory (14). Malnutrition

is preventable and treatable. Awareness, prevention, and intervention need to be initiated in

the local community, in clinical settings, and throughout the nation.

References:

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1. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/000404.htm Accessed

March 30, 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 Don't Elderly Hospital Inpatients Eat Adequately? BNET.

Available at: http://findarticles.com/p/articles/mi_7616/is_200804/ai_n32282136/ .

Accessed March 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

underdiagnosed and undertreated. Nutrition. 2008; 24: 604-606.

7. Willis T et al. (2004). Refeeding Syndrome in a Severely Malnourished Child:

Discussion. Medscape Today. Available at:

http://www.medscape.com/viewarticle/489090_4 . Accessed March 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 in

hospitalized 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

Regular Audits and Feedback. The Journal of Nutrition. 2009; 139,7: 1381-1386.

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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:

http://www.ncbi.nlm.nih.gov/pubmed/11518553 . 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 Guideline Committee. Clinical Nutrition . 2010; 29: 151-153.

14.Availabe at: http://www.bapen.org.uk/pdfs/reports/advisory_group_report.pdf .

Accessed March 30, 2010.

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