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Listen "Malnutrition in the Hospitalized Patient: Diagnosis and Assessment of Unintentional Weight Loss and Malnutrition"
Episode Synopsis
In this episode of Hospital Medicine Unplugged, we take a rapid, evidence-packed tour through unintentional weight loss (UWL) in hospitalized patients—screen fast, diagnose with structure, separate fluid from true tissue loss, and never miss the reversible causes.
We open with the do-firsts: screen within 24–48 hours using MUST, NRS-2002, SNAQ, or MST; older adults get the MNA-SF. Positive screen? Move straight into GLIM—you need ≥1 phenotypic + ≥1 etiologic criterion before calling malnutrition.
Phenotypics: weight loss >5% in 6 months or >10% beyond, low BMI (<20 if <70 years; <22 if ≥70), or reduced muscle mass (BIA, DXA, CT, ultrasound).
Etiologics: reduced intake/assimilation or inflammation/disease burden—the cytokine-driven catabolic engine that overrides normal starvation physiology.
We highlight the epidemiology: UWL hits 20–50% of hospitalized older adults and drives higher mortality, LOS, functional decline, and readmissions—often independent of disease severity. Causes cluster into malignancy, GI disease, psychiatric disease, endocrine disorders, chronic infections, and a surprisingly large fraction (6–28%) with no clear etiology even after thorough workup.
Then the diagnostic sprint: CBC, BMP/CMP, LFTs, ultrasensitive TSH, CRP/ESR, LDH, UA, and age-appropriate cancer screenings. Chest radiography + fecal occult blood testing are universal; abdominal ultrasound or CT follows red flags. GI symptoms trigger stool culture, O&P, C. diff, malabsorption labs, or endoscopy. Never trust albumin or prealbumin—they track inflammation, not nutrition.
We hit the pitfalls hard: fluid shifts mimic weight loss, medications blunt taste and appetite, oral/dental disease gets missed, dysphagia hides in plain sight, and depression in older adults presents without sadness. EPI masquerades as IBS or celiac. Adrenal insufficiency is chronically underdiagnosed. Thyroid–diabetes interactions derail metabolic signals. Failure to screen early, recheck every 7–10 days, or document true intake leads to cascading errors.
Management? Treat the cause and build the nutritional core. Energy 20–30 kcal/kg and protein 0.8–1.5 g/kg, tailored to inflammation severity. For confirmed malnutrition, dietitian-led counseling + fortified oral supplements improve outcomes across major RCTs. Medication reconciliation is mandatory; polypharmacy wrecks appetite. Address oral pain, dentition, dysphagia, and social barriers.
We zoom in on hospital-acquired malnutrition—driven by fasting orders, mealtime interruptions, poor food service quality, inadequate feeding assistance, multimorbidity, and long LOS. Solutions use organizational muscle: protected mealtimes, dietitian-MD collaboration, patient-centered menus, protocolized swallow evaluation, early mobility, and automated rescreening.
For complex cases, we pull in the consultants:
• GI for EPI, celiac, IBD, structural lesions
• Endocrinology for thyroid disease, diabetes interactions, adrenal insufficiency
• Psychiatry for depression, appetite changes, cognitive decline
• ID for TB, HIV, chronic infections
• Nutrition for intake monitoring, body composition, and intervention planning
We close with the system moves: a UWL bundle that (1) screen-within-48h defaults; (2) GLIM-confirmation pathways; (3) early imaging + stool studies when indicated; (4) intake-tracking dashboards; (5) medication-effect flags; (6) fluid-vs-tissue differentiation via calf circumference + composition tools; (7) 7–10-day reassessment; (8) multidisciplinary escalation; and (9) cause-specific tracks (malabsorption, malignancy, endocrine, psychiatric).
Fast, structured, and inflammation-aware—screen early, diagnose precisely, distinguish fluid from tissue, treat the cause, and don’t let hospital factors sabotage recovery.
We open with the do-firsts: screen within 24–48 hours using MUST, NRS-2002, SNAQ, or MST; older adults get the MNA-SF. Positive screen? Move straight into GLIM—you need ≥1 phenotypic + ≥1 etiologic criterion before calling malnutrition.
Phenotypics: weight loss >5% in 6 months or >10% beyond, low BMI (<20 if <70 years; <22 if ≥70), or reduced muscle mass (BIA, DXA, CT, ultrasound).
Etiologics: reduced intake/assimilation or inflammation/disease burden—the cytokine-driven catabolic engine that overrides normal starvation physiology.
We highlight the epidemiology: UWL hits 20–50% of hospitalized older adults and drives higher mortality, LOS, functional decline, and readmissions—often independent of disease severity. Causes cluster into malignancy, GI disease, psychiatric disease, endocrine disorders, chronic infections, and a surprisingly large fraction (6–28%) with no clear etiology even after thorough workup.
Then the diagnostic sprint: CBC, BMP/CMP, LFTs, ultrasensitive TSH, CRP/ESR, LDH, UA, and age-appropriate cancer screenings. Chest radiography + fecal occult blood testing are universal; abdominal ultrasound or CT follows red flags. GI symptoms trigger stool culture, O&P, C. diff, malabsorption labs, or endoscopy. Never trust albumin or prealbumin—they track inflammation, not nutrition.
We hit the pitfalls hard: fluid shifts mimic weight loss, medications blunt taste and appetite, oral/dental disease gets missed, dysphagia hides in plain sight, and depression in older adults presents without sadness. EPI masquerades as IBS or celiac. Adrenal insufficiency is chronically underdiagnosed. Thyroid–diabetes interactions derail metabolic signals. Failure to screen early, recheck every 7–10 days, or document true intake leads to cascading errors.
Management? Treat the cause and build the nutritional core. Energy 20–30 kcal/kg and protein 0.8–1.5 g/kg, tailored to inflammation severity. For confirmed malnutrition, dietitian-led counseling + fortified oral supplements improve outcomes across major RCTs. Medication reconciliation is mandatory; polypharmacy wrecks appetite. Address oral pain, dentition, dysphagia, and social barriers.
We zoom in on hospital-acquired malnutrition—driven by fasting orders, mealtime interruptions, poor food service quality, inadequate feeding assistance, multimorbidity, and long LOS. Solutions use organizational muscle: protected mealtimes, dietitian-MD collaboration, patient-centered menus, protocolized swallow evaluation, early mobility, and automated rescreening.
For complex cases, we pull in the consultants:
• GI for EPI, celiac, IBD, structural lesions
• Endocrinology for thyroid disease, diabetes interactions, adrenal insufficiency
• Psychiatry for depression, appetite changes, cognitive decline
• ID for TB, HIV, chronic infections
• Nutrition for intake monitoring, body composition, and intervention planning
We close with the system moves: a UWL bundle that (1) screen-within-48h defaults; (2) GLIM-confirmation pathways; (3) early imaging + stool studies when indicated; (4) intake-tracking dashboards; (5) medication-effect flags; (6) fluid-vs-tissue differentiation via calf circumference + composition tools; (7) 7–10-day reassessment; (8) multidisciplinary escalation; and (9) cause-specific tracks (malabsorption, malignancy, endocrine, psychiatric).
Fast, structured, and inflammation-aware—screen early, diagnose precisely, distinguish fluid from tissue, treat the cause, and don’t let hospital factors sabotage recovery.
In God we trust