Elsevier

Clinical Nutrition

Volume 35, Issue 6, December 2016, Pages 1450-1456
Clinical Nutrition

Original article
Unsatisfactory knowledge and use of terminology regarding malnutrition, starvation, cachexia and sarcopenia among dietitians

https://doi.org/10.1016/j.clnu.2016.03.023Get rights and content

Summary

Background & aims

Clinical signs of malnutrition, starvation, cachexia and sarcopenia overlap, as they all imply muscle wasting to a various extent. However, the underlying mechanisms differ fundamentally and therefore distinction between these phenomena has therapeutic and prognostic implications. We aimed to determine whether dietitians in selected European countries have ‘sufficient knowledge’ regarding malnutrition, starvation, cachexia and sarcopenia, and use these terms in their daily clinical work.

Methods

An anonymous online survey was performed among dietitians in Belgium, the Netherlands, Norway and Sweden. ‘Sufficient knowledge’ was defined as having mentioned at least two of the three common domains of malnutrition according to ESPEN definition of malnutrition (2011): ‘nutritional balance’, ‘body composition’ and ‘functionality and clinical outcome’, and a correct answer to three cases on starvation, cachexia and sarcopenia. Chi-square test was used to analyse differences in experience, work place and number of malnourished patients treated between dietitians with ‘sufficient knowledge’ vs. ‘less sufficient knowledge’.

Results

712/7186 responded to the questionnaire, of which data of 369 dietitians were included in the analysis (5%). The term ‘malnutrition’ is being used in clinical practice by 88% of the respondents. Starvation, cachexia and sarcopenia is being used by 3%, 30% and 12% respectively. The cases on starvation, cachexia and sarcopenia were correctly identified by 58%, 43% and 74% respectively. 13% of the respondents had ‘sufficient knowledge’. 31% of the respondents identified all cases correctly. The proportion of respondents with ‘sufficient knowledge’ was significantly higher in those working in a hospital or in municipality (16%, P < 0.041), as compared to those working in other settings (7%).

Conclusions

The results of our survey among dietitians in four European countries show that the percentage of dietitians with ‘sufficient knowledge’ regarding malnutrition, starvation, cachexia and sarcopenia is unsatisfactory (13%). The terms starvation, cachexia and sarcopenia are not often used by dietitians in daily clinical work. As only one-third (31%) of dietitians identified all cases correctly, the results of this study seem to indicate that nutrition-related disorders are suboptimally recognized in clinical practice, which might have a negative impact on nutritional treatment. The results of our study require confirmation in a larger sample of dietitians.

Introduction

Malnutrition can be described as “a state resulting from lack of intake or uptake of nutrition that leads to altered body composition (decreased fat-free mass) and body cell mass, leading to diminished physical and mental function and impaired clinical outcome from disease” [1], [2]. Malnutrition is being used as an umbrella term for various nutrition-related disorders [2], like starvation, cachexia and sarcopenia. Starvation can be described as a pure deficit of food intake resulting in gradual loss of both fat mass and muscle mass [3]. Cachexia has been defined as “a complex metabolic syndrome associated with underlying illness and characterized by loss of muscle with or without loss of fat mass” [4]. Whereas cachexia is related to chronic to subacute disease, sarcopenia can be considered a geriatric syndrome [5], characterized by the age-associated loss of skeletal muscle mass and function [6].

Clinical signs of malnutrition, starvation, cachexia and sarcopenia overlap, as they all imply muscle wasting to a various extent, however the underlying mechanisms differ fundamentally and therefore distinction between these phenomena has therapeutic and prognostic implications. In contrast to starvation, optimal nutritional therapy will not fully reverse decline of muscle mass in cachectic patients [7], although this depends on the stage of the cachexia process [8]. Furthermore, sarcopenia is a multifactorial condition in which not only nutritional deficits play a role, but also age-related hormonal deregulation, changes in the neuromuscular system and mitochondrial function, as well as genetic susceptibility and sedentary behavior [5].

It has been reported that better nutritional knowledge results in better nutritional practice [9]. To be able to distinguish starvation, cachexia, and sarcopenia from the umbrella term malnutrition, sufficient knowledge on the characteristics and underlying etiology of these phenomena is of utmost importance, to select adequate treatment. Thus far, the level of knowledge on the mentioned nutrition-related disorders among dietitians has not been extensively explored. A study in Australian dietitians reported that only 6% of the respondents correctly identified starvation, 21% cachexia and 46% sarcopenia in provided cases [10]. Furthermore, an American survey showed that only 50% of the respondents, mostly dietitians, were familiar with the 2012 Consensus Statement from the Academy of Nutrition and Dietetics on adult malnutrition [11].

In this study, we primarily aimed to determine whether dietitians in selected European countries have sufficient knowledge regarding malnutrition, starvation, cachexia and sarcopenia, and use these terms in their daily clinical work. We hypothesized that respondents with more experience or treating more malnourished patients, or those working in a hospital or in municipality (including nursing homes), have more sufficient knowledge. Secondly, we aimed to provide an overview of current practices regarding diagnosis and treatment of nutrition-related disorders.

Section snippets

Study population

This study was performed among dietitians in Belgium, the Netherlands, Sweden, and Norway, who were recruited via national and regional Associations of Dietitians. Members of these associations received an email request from their association, with information on the study and a link to the anonymous online questionnaire. Dutch dietitians were invited to participate in the study via social media as well. In Belgium, both the Flemish and the French Association of Dietitians participated in

Results

A total number of 712 persons responded to the online questionnaire, of which 369 respondents were included in the analysis (Fig. 1). The group of 343 excluded respondents consisted of 53 students and 290 persons with incomplete answers to the key questions. Demographic characteristics of the respondents are shown in Table 2. Respondents that did not complete the mandatory questions included a larger percentage with little or no experience (27%; 77/290), as compared to those that completed all

Discussion

In this survey performed in four Western European countries, we found a low percentage (13%) of dietitians with ‘sufficient knowledge’ regarding malnutrition, starvation, cachexia and sarcopenia. We also found that the terms starvation, cachexia and sarcopenia are not often used by dietitians in daily clinical work. Less than half of the respondents sufficiently scored on the definition of malnutrition. Moreover, only one third of the respondents identified all cases correctly. The findings of

Conflict of interest

No conflicts of interest.

Acknowledgements

We would like to thank Alison Yaxley and Michelle D. Miller for their original research and for providing us the questionnaire used in their study. Also we would like to thank Nieske de Boer and Elke Lammens, for participating in the data collection in the Netherlands and Belgium.

References (23)

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