Malnutrition in the hospital: www.nutritionfornormalpeople.com

1. Malnutrition in the Hospital
DTC 671
4/8/2010
Corrie Cox
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2. 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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3. 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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4. 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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5. 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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6. 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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7. 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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8. (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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9. 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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10. (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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11. 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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12. 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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13. 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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14. 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
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15. inflammation can be termed “acute disease or injury-related malnutrition (13).”
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.
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16. References:
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
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17. Regular Audits and Feedback. The Journal of Nutrition. 2009; 139,7: 1381-1386.
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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