title: Underrecognition of Malnutrition in Advanced Cancer: The Role of the Dietitian and Clinical Practice Variations.
abstract: BACKGROUND
  Malnutrition (MN) often goes unrecognized due to ineffective screening techniques. Published standards for multidisciplinary care exist but no consensus on best nutritional assessment for hospitalized patients. Malnutrition is common in cancer and adversely affects clinical outcomes. The Cleveland Clinic Nutrition Therapy Department used in-house criteria to classify MN in hospitalized patients. This study aimed to evaluate the registered dietitian (RD)'s role, the use of these criteria in the acute care palliative medicine unit (ACPMU), and investigate MN prevalence and severity among admitted patients with cancer.
  
  
  METHODS
  Electronic medical records were reviewed for newly admitted patients with cancer to the ACPMU with a first time RD consult and completed nutritional therapy assessment. Physician (MD) assessments were derived from admission notes. Cox regression model assessed the association of MN prevalence and severity with survival. McNemar's test determined whether a prevalence difference existed between RD and MD.
  
  
  RESULTS
  Variations existed in criteria used to identify MN. Seventy percent had MN, with the majority (61%) classed as moderate to severe. Prevalence (hazard ratio [HR]: 1.88; P = .002) and severity (HR: 1.22; P = .006) were associated with significantly increased mortality. Evaluations by RD and MD were highly congruent, but MDs underrecorded nutritional status.
  
  
  CONCLUSIONS
  Malnutrition was prevalent and clinically important, even in those on nutritional support. Variations in MN identification were common. Physicians underrecorded MN but were accurate for prevalence and severity when recorded. The data confirm the RD's important role in MN assessment. Comparable clinical practice and better communication between physicians and dietitians should improve cancer care and optimize quality of life.
authors.affiliation: 1 Section of Palliative Medicine and Supportive Oncology, Department of Solid Tumor Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA.|2 The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Aynur
authors.initials: A
authors.lastname: Aktas
authors.affiliation: 1 Section of Palliative Medicine and Supportive Oncology, Department of Solid Tumor Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA.|2 The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic, Cleveland, OH, USA.|3 Faculty of Health Sciences, Trinity College, Dublin 2, Ireland.
authors.forename: Declan
authors.initials: D
authors.lastname: Walsh
authors.affiliation: 4 Section of Nutrition, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Marianne
authors.initials: M
authors.lastname: Galang
authors.affiliation: 3 Faculty of Health Sciences, Trinity College, Dublin 2, Ireland.
authors.forename: Niamh
authors.initials: N
authors.lastname: O'Donoghue
authors.affiliation: 5 Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Lisa
authors.initials: L
authors.lastname: Rybicki
authors.affiliation: 1 Section of Palliative Medicine and Supportive Oncology, Department of Solid Tumor Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA.|2 The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Barbara
authors.initials: B
authors.lastname: Hullihen
authors.affiliation: 1 Section of Palliative Medicine and Supportive Oncology, Department of Solid Tumor Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA.|2 The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Ellen
authors.initials: E
authors.lastname: Schleckman
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004035:Diet Therapy / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D044342:Malnutrition / Q000178:diet therapy* / Q000209:etiology*; D008875:Middle Aged; D009369:Neoplasms / Q000150:complications*; D009752:Nutritional Status; D018529:Nutritional Support / Q000592:standards*; D064686:Nutritionists / Q000592:standards*; D010166:Palliative Care / Q000592:standards*; D024382:Professional Role
keywords: cancer; dietitian; malnutrition; prognosis; symptoms; weight loss