Protein-energy malnutrition in hospitalized patients: early assessment for better outcome.

tion [4]. Whereas cachexia is always an expression of a disease accompanied by enormous changes in body composition with a grave prognosis due to increased and progressive protein catabolism, hospital malnutrition may result from poor intake due to reversible etiologies, such as acute infection, low food availability, and depression. This is in contrast to chronic wasting diseases with a poor prognosis, such as advanced dementia or any severe organ failure. A recent international consensus committee has proposed revised definitions of malnutrition [5]. “Starvation-related malnutrition” develops in cases of chronic starvation without inflammation, “chronic disease-related malnutrition” is diagnosed in cases with mild to moderate degrees of inflammation, and “acute diseaseor injury-related malnutrition” occurs when inflammation is acute and of severe degree. This stratification highlights the emerging role of pro-inflammatory cytokines that mediate complicated starvation. Such definitions are in line with the traditional historical types of protein-energy malnutrition, namely – marasmus, which is due to low energy intake over a prolonged period and has a relatively benign clinical course, and kwashiorkor, which is characterized by an acute disease course due to low protein and energy resources [6]. Whereas marasmus leads mainly to fat deposit depletion, kwashiorkor or proteinenergy malnutrition with stress-associated malnutrition leads to accelerated depletion of muscle and visceral organs with ensuing high mortality rates. Numerous studies have demonstrated the extent of malnutrition in hospitals, with a prevalence reaching 50% dependt he 20th century was characterized by major developments in nutrition science and practice: deficiency syndromes of macroand micro-nutrients were defined, the pathophysiological basis and clinical consequences of human starvation were investigated, and dietary requirements were formulated [1]. Until the 1970s it was thought that malnutrition was a phenomenon that existed exclusively in developing countries and in areas of the world under crisis and economic instability. Later it became apparent that the problem of malnutrition existed also in hospitalized patients and in various disease states, in both medical and surgical patients, in different countries [2,3]. In general, malnutrition is used to describe a wide spectrum of conditions with an imbalance between intake and requirements, ranging from undernutrition to over-nutrition. Usually, under-nutrition follows reduced food intake, increased body requirements, malabsorption syndromes, or any combination of such states. ESPEN, the European Society for Clinical Nutrition and Metabolism (formerly the European Society of Parenteral and Enteral Nutrition) presented a consensus document that contained an adapted definition of malnutrition that distinguishes between cachexia, sacropenia (loss of muscle mass and function) and malnutriing on the patient population and the criteria of malnutrition [7]. For instance, a British study that is frequently cited on the subject investigated 500 patients in an acute-care teaching hospital in Dundee, Scotland. An underweight prevalence of 40% (body mass index < 20 kg/m2) was observed with a 5.4% further weight loss in 112 patients reassessed on discharge. Under-nutrition was not recognized during the hospital stay in most of these patients [8]. The German Hospital Malnutrition Study diagnosed malnutrition in 27.4% of 1886 patients admitted to private and university hospitals [9]. Malnutrition was present in 48.1% of 4000 patients in hospitals in Brazil, but only 18.8% of patients’ records provided any nutrition-related information [10]. A Danish study screened 750 patients and found that 22% were at risk for malnutrition, while dietary plans and records were missing in the majority of these patients [11]. To complete the wide geographic distribution of studies, a recent review has illustrated the extent and implications of malnutrition in the Australian health system [7]. Nutrition assessment comprises a history-taking, and physical, clinical, biochemical and anthropometric evaluation. Numerous scoring systems for nutritional screening have been developed. The longest in use is the SGA (Subjective Global Assessment), which looks at 10 items – 5 in patient history and 5 in physical examination – ranking them as well nourished, moderate nutrition and severe malnutrition [12]. The MUST (Malnutrition Universal Screening) was developed in the UK and utilized BMI, unintentional