140

ORIGINAL

Impact of a multidisciplinary rehabilitation nutrition team on
evaluating sarcopenia, cachexia and practice of
rehabilitation nutrition
Yoji Kokura, RD1 ; Hidetaka Wakabayashi, MD, PhD2 ; Keisuke Maeda, MD, PhD3 ; Shinta Nishioka, RD4 ;and Saori Nakahara, RD5.
1

Department of Clinical Nutrition, Keiju Medical Center, 94 Tomioka - chou, Nanao city, Ishikawa 926 - 8605, Japan, 2Department of Rehabilitation Medicine, Yokohama City University Medical Center, 4 - 57 Urafune - chou, Minami ward, Yokohama city, Kanagawa 232 - 0024, Japan,
3Department of Nutrition and Dysphagia Rehabilitation, Tamana Regional Health Medical Center, 2172 Tamana, Tamana city, Kumamoto
865 - 0005, Japan, 4Department of Clinical Nutrition and Food Services, Nagasaki Rehabilitation Hospital, 4 - 11 Gin - ya machi, Nagasaki
city, Nagasaki 850 - 0854, Japan, 5Department of Nutrition, Suzuka General Hospital, 1275 - 53 Yamanohana, Yasuduka - chou, Suzuka city,
Mie 513 - 8630, Japan

Abstract : Background/Aims : To determine whether the presence of a multidisciplinary rehabilitation nutritionteam affects sarcopenia and cachexia evaluation and practice of rehabilitation nutrition. Methods : A cross -sectional study using online questionnaire among members of the Japanese Association of Rehabilitation Nutrition(JARN) was conducted. Questions were related to sarcopenia and cachexia evaluation and practice of rehabilitation nutrition. Results : 677 (14.7%%) questionnaires were analysed. 44.5%% reported that their institution employed a rehabilitation nutrition team, 20.2%% conducted rehabilitation nutrition rounds and 26.1%% conductedrehabilitation nutrition meetings. A total of 51.7%%, 69.7%%, 69.0%% and 17.8%% measured muscle mass, muscle strength,
physical function and cachexia, respectively. For those with a rehabilitation nutrition team, 63.5%%, 80.7%%, 82.4%
and 22.9%% measured muscle mass, muscle strength, physical function and cachexia, respectively, whereas 46.7%%,
78.0%% and 78.1%% of the respondents reported implementation of nutrition planning strategies in considerationof energy accumulation, rehabilitation training in consideration of nutritional status and use of dietary supplements, respectively. Multivariate logistic regression analysis showed that the use of a rehabilitation nutritionteam independently affected sarcopenia evaluation and practice of rehabilitation nutrition but not cachexia evaluation. Conclusions : The presence of a multidisciplinary rehabilitation nutrition team increased the frequency ofsarcopenia evaluation and practice of rehabilitation nutrition. J. Med. Invest. 64 : 140-145, February, 2017
Keywords : Cachexia, Multidisciplinary team, Questionnaire, Rehabilitation nutrition, Sarcopenia

INTRODUCTION
The high prevalence of malnutrition, sarcopenia and cachexia
among people with disabilities remains a global problem. The prevalence of protein energy malnutrition in hospitalized older patientsis reported to range between 30% and 90%, and 50.5% of patients inrehabilitation facilities, the highest proportion among all settings(1-3). Meanwhile, the prevalence of sarcopenia is 8-50% in persons
aged !60 years (4 -6) and that of cachexia is 5-15% in those with
end-stage chronic heart failure and 50-80% in those with advanced
cancer (7). The overall prevalence of cachexia is approximately
1% of the patient population, affecting an estimated 9 million people
worldwide (7). Moreover, sarcopenia is often accompanied withmalnutrition (8) ; it is estimated to affect over 50 million people
worldwide, and this number is expected to increase to more than
2 billion in the next 40 years (9). Therefore, countermeasures toprevent sarcopenia and cachexia are very important.
Rehabilitation nutrition is a combination of both rehabilitationand nutrition care management that exert maximal function, activities and participation of persons with disabilities (10). Intervention
with rehabilitation nutrition can improve activities of daily living,
Received for publication September 27, 2016 ; accepted February 1,
2017.

muscle mass and strength, sarcopenic dysphagia and cachexia(11 -15). Implementation of nutrition planning in consideration ofenergy accumulation, rehabilitation training with emphasis on nutritional status and use of dietary supplements can help alleviatemalnutrition, sarcopenia and cachexia in persons with disabilities.
A multidisciplinary rehabilitation nutrition team may be effective
to evaluate sarcopenia and cachexia. The diagnosis of sarcopenia
relies on three indicators : muscle mass, muscle strength and physical performance (9). Assessment of the prevalence and causes ofsarcopenia in persons with disabilities is also important in rehabilitation nutrition because the practice of rehabilitation nutrition depends on the aetiology of sarcopenia (1). The use of a multidisciplinary team could decrease the incidence of inappropriate druguse, shorten the length of hospitalisation and reduce total medical
costs (16) and mortality (17). However, it remains unclear whether
the presence of a multidisciplinary rehabilitation nutrition team affects the frequency of sarcopenia and cachexia evaluation and thepractice of rehabilitation nutrition. Hence, further studies to assess
knowledge of sarcopenia and cachexia among members of the interdisciplinary team in addition to dietitians are required (18).
The purpose of this study was to determine whether the presence of a multidisciplinary rehabilitation nutrition team affects thefrequency of sarcopenia and cachexia evaluation and practice of
rehabilitation nutrition.

Address correspondence and reprint requests to Yoji Kokura, Registered dietitian. Department of Clinical Nutrition, Keiju Medical Center,
94 Tomioka chou, Nanao city, Ishikawa 926 - 8605, Japan and Fax : + 81 0767 - 52 - 3218.

The Journal of Medical Investigation Vol. 64 2017

The Journal of Medical Investigation

METHODS
1. Participants
The study participants were members of the Japanese Association of Rehabilitation Nutrition (JARN), which was established in2011 (10) and includes 4621 members. The JARN established a
Facebook group to encourage communication among members.
Inclusion criteria were consent to participate in this study and response to the questionnaire. Responses to the questionnaires were
excluded if data were missing or included a duplicative answer.

2. Questionnaire period and methods
The survey period was 2 weeks, November 8 to 22, 2015. The
questionnaire was distributed using the Facebook group of the
JARN, which included a description of the purpose and contentsof the questionnaire survey. The survey was conducted online.
Verification of the validity of questions and readability were determined by conducting pre-tests. Question items (Table 1) were related to the frequency of sarcopenia and cachexia evaluation andthe practice of rehabilitation nutrition assessment.

3. Formation of a team to implement rehabilitation nutrition
Rehabilitation nutrition is similar to sports nutrition in that it consists of both rehabilitation and nutrition care management. This
concept was devised by the International Classification of Functioning, Disability and Health (ICF) to assess nutritional status tomaximise functionality of persons with disabilities (10). Rehabilitation nutrition team is a kind of nutrition support team. In addition
to the normal nutritional support, this emphasizes on nutritional
management and takes into account life function and rehabilitation
program (rehabilitation as seen from nutrition management) andrehabilitation training with emphasis on nutritional status, nutritional intake and nutrition management (nutrition management asseen from rehabilitation). In addition, this team encourages theintake of oral nutritional supplements with high-branched-chainamino acids immediately after rehabilitation training and implements nutrition support, which is a combination of both rehabilitation and nutrition care management. Furthermore, rehabilitation
nutrition team proposes an attending physician for the rehabilitation nutrition care plan. The criteria were evaluated by a rehabilitation nutrition team during rehabilitation nutrition rounds andrehabilitation nutrition meetings. The following seven items werecomprehensively assessed to meet the standards of the ICF : (1)Evaluation of current nutritional status management strategies ;(2) Evaluation of each item in the ICF ; (3) Current training content
of rehabilitation programs ; (4) Prognosis of nutritional status andgoal setting ; (5) Prognosis of rehabilitation goals and goal setting ;(6) Nutrition management plan in consideration of rehabilitation
training ; (7) Rehabilitation plan in consideration of nutritional
status. The rehabilitation nutrition team discusses strategies toimplement items (1) to (7). The rehabilitation nutrition roundrefers to bedside visits by the rehabilitation nutrition team. Rehabilitation nutrition meetings refer to conversations or exchanges
of information about functional evaluation, prognosis and rehabilitation training content between disciplines.

4. Evaluation of cachexia
Evaluation method of cachexia was investigated about the guidelines of the European Palliative Care Research Collaborative (19,20) or definition of the Washington consensus meeting (21). Diagnostic criteria for cachexia of European Palliative Care Research
Collaborative was weight loss greater than 5%, or weight loss greaterthan 2% in individuals already showing depletion according to current bodyweight and height (body-mass index [BMI] !20 kg/m(2)) or the loss of skeletal muscle mass (sarcopenia) (19, 20). Diagnostic criteria for cachexia by the definition of the Washington

Vol. 64 February 2017141

consensus meeting were weight loss of at least 5% in 12 months
or less in the presence of underlying illness, plus any three of thefollowing criteria : decreased muscle strength fatigue, anorexia,
low fat-free mass index, abnormal biochemistry (21).

5. Data Analysis
A sample size of more than 664 persons, under assumptions of
two-choice question, and 50% selection with a 5% error based on
99% reliability were found to be necessary. Categorical data areexpressed as percentages, and differences were analysed using theChi-square test. Multivariate logistic regression analysis was performed to identify the variables that were independently associatedwith each outcome (measure of muscle mass, muscle strength andphysical function, evaluation of cachexia and activities of daily living, the implementation of nutrition planning in consideration of
the degree of activity and the implementation of nutrition planningin consideration of energy accumulation, rehabilitation training
with emphasis on nutritional status and use of dietary supplements).
Factors with a low incidence were excluded from multivariate logistic regression analysis and were described ‘not available’. Variance inflation factors (VIFs) were used to evaluate multicollinearity
for each model. We considered a VIF value of "2 as demonstrating
multicollinearity. In all cases, a p value of !0.05 was considered
statistically significant. All statistical analyses were performed
using EZR (22) software ver. 1.31, which was developed from theopen-source statistical software R (23).

6. Ethical considerations
Informed consent was obtained from all participants. The questionnaires were completed anonymously to protect personal information and guaranteed confidentiality to the respondents. The
study protocol was approved by the ethics committee of Suzuka
General Hospital (Suzuka, Japan) and conducted in accordancewith the tenets of the 1964 Declaration of Helsinki and its later
amendments.

RESULTSOf a total of 716 completed questionnaire that were received,
39 (5.4%) were excluded from analysis due to anomalies in the responses (19 completed questionnaires filled by respondents working at a clinic, pharmacy, or dental clinic were excluded becauseof the little relationship to team activity, 13 questionnaires had
duplication, 6 had missing values and 1 contained obvious inconsequential responses to key questions). Consequently, 677 questionnaires were included for analysis (14.7% response rate).
As shown in Table 1,affiliation of the respondents included acutegeneral wards (303, 44.7%), convalescent rehabilitation wards(176, 26.0%), medical care or long-term care facilities (50, 7.4%),
long-term care health facilities (51, 7.5%), homecare services (44,6.5%), other hospitals (29, 4.3%), educational institutions (7, 1.0%),
regional comprehensive care wards (3, 0.5%), day services, visiting
nursing and outpatient rehabilitation (6, 0.9%) and others (8, 1.2%).
The median length of work experience was 11 (interquartile range,
7 -18) years. Of all respondents, 44.5% employed rehabilitation nutrition teams, 20.2% employed rehabilitation nutrition rounds and26.1% conducted rehabilitation nutrition meetings. Of the respondents, 51.7%, 69.7%, 69.0%, 86.1% and 17.8% reported that muscle
mass, muscle strength, physical function, activities of daily living
and cachexia, respectively, were regularly measured. A total of
59 (48.7%) and 44 (36.3%) respondents, respectively, reported thatthe methods for evaluation of cachexia were based on the European Palliative Care Research Collaborative guidelines or the Washington consensus meeting. Also, 46.7%, 78.0% and 78.1% of the
respondents reported implementation of nutrition planning in142

Y. Kokura, et al. Rehabilitation nutrition and sarcopenia

Table 1. Questionnaire and sample characteristics
1. What is your occupation?
Total, n (%)
Medical doctor, n (%)
Dentist, n (%)
Nurse, n (%)
Pharmacist, n (%)
Registered dietitian, n (%)
Physical therapist, n (%)
Occupational therapist, n (%)
Speech therapist, n (%)
Dental hygienist, n (%)
Others, n (%)
2. What is your affiliation?
Acute general ward, n (%)
Convalescent rehabilitation ward, n (%)
Medical care or long - term care ward, n (%)
Long - term care health facility, n (%)
Homecare service, n (%)
Other hospital, n (%)
Educational institution, n (%)
Regional comprehensive care ward, n (%)
Day service, Visiting nursing and Outpatient Rehabilitation, n (%)
Others, n (%)
3. How many years of work experience?
Year(s), median (25% - 75%)
4. Is there a rehabilitation nutrition team in your facility?
Yes, n (%)
No, n (%)
Medical doctor, n (%)
Dentist, n (%)
Nurse, n (%)
Pharmacist, n (%)
Registered dietitian, n (%)
Physical therapist, n (%)
Occupational therapist, n (%)
Speech therapist, n (%)
Dental hygienist, n (%)
Others, n (%)
5. Are rehabilitation nutrition rounds conducted in your facility?
Yes, n (%)
No, n (%)
6. Are rehabilitation nutrition meetings conducted in your facility?
Yes, n (%)
No, n (%)
7. Do you measure muscle mass?
Yes, n (%)
No, n (%)
8. Do you measure muscle strength?
Yes, n (%)
No, n (%)
9. Do you measure physical function?
Yes, n (%)
No, n (%)
10. Do you measure activities of daily living?
Yes, n (%)
No, n (%)
11. Do you evaluate cachexia?
Yes, n (%)
No, n (%)
12. How do you evaluate cachexia?
EPCRC guidelines, n (%)
Definition of the Washington consensus meeting, n (%)
13. Do you implement nutrition planning in consideration of activity?
Yes, n (%)
No, n (%)
14. Do you implement nutrition planning in consideration of energy accumulation?
Yes, n (%)
No, n (%)
15. Do you implement rehabilitation training with emphasis on nutritional status?
Yes, n (%)
No, n (%)
16. Do you use dietary supplements?
Yes, n (%)
No, n (%)
17. Have you participated in a congress or seminar of the JARN?
Yes, n (%)
No, n (%)

677 (100)
40 (5.9)
17 (2.5)
56 (8.3)
10 (1.5)
178 (26.3)
193 (28.5)
40 (5.9)112 (16.5)
22 (3.3)
9 (1.3)303 (44.7)
176 (26.0)
50 (7.4)
51 (7.5)
44 (6.5)
29 (4.3)
7 (1.0)3 (0.5)6 (0.9)8 (1.2)11 (7 - 18)
301 (44.5)
376 (55.5)
Yes
25 (8.3)
8 (2.7)24 (8.0)
3 (1.0)68 (22.6)
102 (33.9)
17 (5.7)
44 (14.6)
9 (2.9)1 (0.3)No
15 (4.0)
9 (2.4)32 (8.5)
7 (1.9)110 (29.3)
91 (24.2)
23 (6.1)
68 (18.1)
13 (3.5)
8 (2.1)137 (20.2)
540 (79.8)
177 (26.1)
500 (73.9)350 (51.7)
327 (48.3)
472 (69.7)
205 (30.3)
467 (69.0)
210 (31.0)
589 (86.1)
94 (13.9)
121 (17.8)
556 (82.2)
59 (48.7)
44 (36.3)
345 (51.0)
332 (49.0)
316 (46.7)
361 (53.3)
528 (78.0)
149 (22.0)
529 (78.1)
148 (21.9)
506 (74.7)
171 (25.3)

Abbreviations : EPCRC, European Palliative Care Research Collaborative ; JARN, Japanese Association of Rehabilitation Nutrition

The Journal of Medical Investigation

143

Vol. 64 February 2017of activities of daily living, nutrition planning in consideration ofenergy accumulation and rehabilitation training with emphasis on
nutritional status and use of dietary supplements. However, there
was no significant difference in the frequency of cachexia evaluation between facilities that did or did not employ a rehabilitation
nutrition team. The VIFs did not demonstrate significant multicollinearity between any factors on multivariate analysis.

consideration of energy accumulation, rehabilitation training withemphasis on nutritional status and use of dietary supplements, respectively.
Table 2 shows the results of the univariate analyses regarding
the use of a team to implement rehabilitation nutrition programs.
As described, 63.5%, 80.7%, 82.4%, 22.9% and 93.0% of the rehabilitation nutrition teams measured muscle mass, muscle strengthand physical function and evaluated cachexia and activities of dailyliving, respectively. Also, 64.7%, 89.0% and 89.4% of the rehabilitation nutrition teams reported nutrition planning in considerationof energy accumulation, rehabilitation training with emphasis on
nutritional status and use of dietary supplements, respectively.
Table 3 shows the results of multivariate analyses of each outcome after adjusting for confounding factors, including affiliation,
years of work experience, existence of rehabilitation nutrition teamrounds and existence of rehabilitation nutrition team meetings andattendance of a congress or seminar of the JARN. The employmentof a rehabilitation nutrition team affects the measurement of muscle mass and strength, measurement of physical function, evaluation

DISCUSSION
There were three important clinical findings of the present study.
First, the presence of a multidisciplinary rehabilitation nutritionteam was associated with a high frequency of implementing measures of muscle mass, muscle strength and physical performancefor evaluation of sarcopenia. Second, the existence of rehabilitation
nutrition team was not significantly associated with cachexia evaluation. Third, a high proportion of facilities having multidisciplinary
rehabilitation nutrition teams implemented rehabilitation nutrition

Table 2. Univariate analysis of teams for implementation of rehabilitation nutrition programs
Characteristics

Implementation

Presence of a rehabilitation nutrition teamYes

Measurement of muscle mass
Measure of muscle strength
Measure of physical function
Evaluation of cachexia
Evaluation of activities of daily living

Yes, n (%)

191 (63.5)

159 (42.3)

No, n (%)

110 (36.5)

217 (57.7)

Yes, n (%)

243 (80.7)

229 (60.9)

No, n (%)

58 (19.3)

147 (39.1)

Yes, n (%)

248 (82.4)

219 (58.2)

No, n (%)

53 (17.6)

157 (41.8)

Yes, n (%)

69 (22.9)

52 (13.8)

No, n (%)

232 (77.1)

324 (86.2)

Yes, n (%)

280 (93.0)

303 (80.6)

No, n (%)

21 (7.0)73 (19.4)

Nutrition planning in consideration of energy
accumulation

Yes, n (%)

195 (64.7)

121 (32.2)

No, n (%)

106 (35.3)

255 (67.8)

Rehabilitation training with emphasis on
nutritional status

Yes, n (%)

268 (89.0)

260 (69.2)

No, n (%)

33 (11.0)

116 (30.8)

Use of dietary supplements

p - valueNo

Yes, n (%)

269 (89.4)

260 (69.2)

No, n (%)

32 (10.6)

116 (30.8)!0.001†!0.001†!0.001†0.002†!0.001†!0.001†!0.001†!0.001††Chi - square test

Table 3. Multivariate logistic regression analysis for each outcome
Measure ofmuscle mass

FactorRehabilitation nutritionteam in the facility
Years of work
experience
Rehabilitation nutritionrounds in the facility

Measure ofmuscle strength

Measure ofphysical function

Evaluate ofcachexia

Evaluate of activities
of daily living

Nutrition planning Rehabilitation training
in consideration ofwith emphasis onenergy accumulation nutritional status

Use of dietary
supplements

OR, 95% CI p - value OR, 95% CI p - value OR, 95% CI p - value OR, 95% CI p - value OR, 95% CI p - value OR, 95% CI p - value OR, 95% CI p - value OR, 95% CI p - value!0.001 3.12
!0.001 1.30
!0.001 2.78
!0.001 2.69
!0.0010.33
2.93
0.002 3.64
1.95
0.001 2.29
1.31 - 2.90
0.99

1.45 - 3.60
0.285

0.96 - 1.01
0.98
1.63
1.04 - 2.55

Participated in congress of
seminar of the JARN

1.30 - 2.69

1.87

1.95 - 5.00
0.77 - 2.18
!0.001 0.96
!0.001 1.02
0.15

0.94 - 0.98
0.934

0.59 - 1.61

Rehabilitation nutrition
meetings in the facility

0.96
1.24

0.93 - 0.98
0.477

0.68 - 2.26
0.031

1.27
1.23
0.84 - 1.81

0.32

0.73 - 2.52
0.368

0.75 - 2.13
0.001

1.36

0.99 - 1.04

0.98

0.92

1.10
0.74 - 1.62

2.45

0.36

1.63
0.97 - 2.73

2.40 - 5.54
0.001

0.82

0.001

0.19

0.66

1.73
1.07 - 2.80

0.45
0.26 - 0.77

0.19

0.77 - 3.68
0.063

1.01

1.64 - 4.71
0.011

1.00 - 1.05

0.34 - 1.99

1.45 - 4.15
0.64

0.95
0.93 - 0.98

0.43 - 1.36

0.57 - 1.64
0.282

0.77

1.48 - 5.80

2.9
1.80 - 4.67

0.025

2.27
1.53 - 3.37

0.99

1.57 - 4.58
0.55

0.96 - 1.02
0.004

1.27

0.533

1.17 - 2.66

Abbreviations : 95% CI, 95% confidence interval ; JARN, Japanese Association of Rehabilitation Nutrition ; OR, odds ratio

1.21

0.629

0.56 - 2.57
0.182

0.81 - 2.87

!0.001 1.76

0.003

0.94 - 0.98

0.59 - 2.69

!0.001 1.53

0.96

2.01

0.038

1.04 - 3.87
0.007

1.19
0.77 - 1.82

0.428

144

Y. Kokura, et al. Rehabilitation nutrition and sarcopenia

strategies.
The presence of a multidisciplinary rehabilitation nutrition teamwas related to a high proportion of institutes measuring muscle
mass, muscle strength and physical performance for evaluationof sarcopenia. Previous studies have reported that 46-74% of institutes regularly evaluated sarcopenia (18, 24). In this study, 51.068.5% regularly evaluated sarcopenia. However, among institutes
that employed a rehabilitation nutrition team, this rate increased
to 63.6 -82.5%. The use of a multidisciplinary team could decrease
the incidence of readmission to a critical care ward (25), lower theincidence of complications (26) and improve functional prognosis(27). Practice-based interprofessional collaboration interventions
can lead to positive changes in health care management (16). The
rehabilitation nutrition team exchanges information about functional evaluation, prognosis and content of rehabilitation training
strategies. In addition, rehabilitation nutrition assessment includes
the presence and cause of sarcopenia. Therefore, the use of a multidisciplinary rehabilitation nutrition team can increase the frequency of sarcopenia evaluation.
The presence of a rehabilitation nutrition team did not affect thefrequency of cachexia evaluation. In older inpatients with hospitalassociated deconditioning, 88% were malnourished and 30% had
precachexia, which was associated with poor rehabilitation outcomes (28). We evaluated pre-cachexia by the European Society
for Clinical Nutrition and Metabolism consensus diagnostic criteria for pre -cachexia. Diagnostic criteria are (i) underlying chronic
disease ; (ii) unintentional weight loss of less than 5% of usual bodyweight during the last 6 months ; (iii) chronic or recurrent systemic inflammatory response and (iv) anorexia or anorexia-related
symptoms (29). Cachexia is more common in older patients andcan adversely affect rehabilitation outcomes. Cachexia assessment
is imperative in rehabilitation nutrition, although the rate of cachexia
evaluation is low compared to that of sarcopenia evaluation. Previous studies reported that the range of cachexia recognition was
21 -43% (18, 24). In this study, implementation rate of cachexia
evaluation by a rehabilitation nutrition team was 17.2%. The low frequency of implementing cachexia evaluation may be due to the low
frequency of cachexia recognition, no uniform criteria for diagnosis of cachexia and complicated diagnosis criteria that require several evaluation items (19-21). Therefore, it is important to develop
uniform criteria for diagnosis of cachexia to increase the frequency
of cachexia evaluation in clinical practice.
A high proportion of facilities having multidisciplinary rehabilitation nutrition teams regularly performed nutrition planning inconsideration of energy accumulation, implemented rehabilitation
training programs with emphasis on nutritional status and useddietary supplements. Originally, the rehabilitation nutrition teamis different from nutrition support and rehabilitation teams in termsof considering energy accumulation, rehabilitation training withemphasis on nutritional status and intake dietary supplement after
rehabilitation. It is rare for nutrition support team to measure muscle strength and physical function. Furthermore, it is meaningful
to consider nutrition planning in consideration of energy accumulation, rehabilitation training with emphasis on nutritional status,
and use of dietary supplements after rehabilitation by the rehabilitation nutrition team. The amount of accumulated energy is added
to the daily energy expenditure to improve malnutrition and sarcopenia. Members of the rehabilitation nutrition team and registereddietitians set nutritional standards and determine energy accumulation, while rehabilitation therapists evaluate rehabilitation-related
energy expenditure. The multidisciplinary rehabilitation nutritionteam encourages weight increases to improve sarcopenia. Rehabilitation and training of a malnourished patient with poor nutritional intake can lead to weight loss, including lean body mass. The
use of dietary supplements can significantly increase energy andprotein intake (30). Therefore, rehabilitation nutrition may improve

rehabilitation outcome in persons with disabilities and sarcopenia.
This study had a few limitations that should be addressed. First,
there may have been overlaps by respondents from the same facility. However, evaluation of sarcopenia and cachexia and rehabilitation nutrition strategies can differ in the same facility. Second, theparticipants were limited to JARN members ; therefore, external
validity is limited. Third, the questionnaire included only two questions for nutritional management. Fourth, the sample of respondents was heterogeneous, with only 5.9% being represented byphysicians. It may have influenced the assessment rate of sarcopenia and cachexia. Fifth, we had not shown the effects of therehabilitation nutrition team on sarcopenia, cachexia, nutritional
status, and prognosis. Lastly, this research was based on a questionnaire survey conducted using the Internet. Therefore, the response rate of subjects was possibly different depending on age
and other demographics, which affected the sample selection. In
the future, we plan to investigate the evaluation of sarcopenia andcachexia and practice of rehabilitation nutrition by medical professions in different countries.
In conclusion, the presence of a multidisciplinary rehabilitation
nutrition team was associated with an increased frequency of sarcopenia evaluation and practice of rehabilitation nutrition but notcachexia evaluation among members of the JARN. The frequency
of cachexia evaluation was lower than that of sarcopenia. Further
prospective studies are required to examine the effect of a rehabilitation nutrition team on improvement in evaluation of nutritional status, sarcopenia, cachexia, activities of daily living andquality of life.

CONFLICTS OF INTEREST
The authors declare that they have no conflict of interest.

ACKNOWLEDGMENT
The authors thank the JARN members for their valuable assistance with this project.

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