Nutrition Essentials | Malnutrition: It’s More Common Than You’d Expect

Podcast Transcript

John Horton:

Hey there, and welcome to another episode of Nutrition Essentials, a side project of our popular Health Essentials Podcast. I'm John Horton, your co-host, with registered dietitian, Julia Zumpano.

Julia Zumpano:

Hey, so today, we are interviewing Krista Mielnik, and she is a dietitian who specializes in malnutrition. Although most of us think of malnutrition … when we think of malnutrition, we may think of starving children in Africa. That's definitely not what we're talking about here. Malnutrition is a very common issue, and it's something where registered dietitians are the top number one provider that will screen and assess and treat malnutrition.

John Horton:

Well, Julia, I know we were talking about how complicated it is to sometimes determine whether somebody is malnourished, and you were saying you've had experience with that just in the patients you see.

Julia Zumpano:

Absolutely. We screen for malnutrition and we grade the severity of their malnutrition, and the severity may indicate the plan and the outcome. So it's very, very challenging to assess malnutrition, especially at times when I'm seeing a patient virtually and I'm not able to do that full nutrition-focused physical exam, and maybe they're poor historians, so I'm not able to get out a lot of what they're eating. So I have to use limited pieces to make my clinical judgment on whether or not they're malnourished, and then, really, more importantly, provide them the best plan. So it's very complicated.

John Horton:

Well, there is a whole lot that goes into it, and we're going to learn more about that with what we talk about next. So give it a listen.

Welcome to the podcast, Krista. I can't tell you how excited we are to have you on and really tackle this topic.

Krista Mielnik:

Yeah, thank you so much for having me. I appreciate it.

John Horton:

Well, thanks for making the time to get us started here. Tell us a little bit about what you do at the clinic, what your role is, and I know you spend a lot of time looking for malnutrition with people.

Krista Mielnik:

Yeah, for sure. Yeah, I work at the Cleveland Clinic at the main campus downtown, and I specifically work with cystic fibrosis patients, so adult patients who have cystic fibrosis, which is a lung disease. But along with that, I do do a lot of work in malnutrition. I co-chair of our malnutrition committee here, and so I do a lot of work in different kinds of research quality initiatives, and even just with my own patients, diagnosing malnutrition, seeing it a lot and talking to other registered dietitians about malnutrition as well.

John Horton:

What really attracted you to that? It seems like that's really a big focus.

Krista Mielnik:

Yeah. For sure. I would say, initially, in our training as dietitians within my internship and my graduate degree work, malnutrition was always a big topic. Particularly at that time, it was just starting to come out as being kind of more specific diagnostic criteria. And so it was like the hot topic at the time.

And now at the Cleveland Clinic, it's such a huge focus for the registered dietitians because we really are the integral part of diagnosing, malnutrition and intervening with patients who have it and just really advocating for it on the interdisciplinary team.

So the Cleveland Clinic has really just even focused me more on malnutrition and the importance of it, and so that was really why I was interested in it in the first place. But then also, just the populations that I've worked with, not only just cystic fibrosis, but also, prior to that and other areas, like oncology or transplant patients, malnutrition is such a big issue. And so that really focused me, too, on the subject of it.

John Horton:

Yeah, it's a huge issue everywhere in the world. I mean, I saw where the World Health Organization lists malnutrition as one of the biggest public health threats out there. So obviously, it's a big topic and it deserves attention, which is why you're here with us today. So just to get us started, let's spend some time just defining what malnutrition is because I think everyone's got a little idea, but let's really try to drill down there.

Krista Mielnik:

Yeah. For sure. So in terms of the term “malnutrition,” that can really be defined as just a nutrition imbalance in general. But for the purposes of our conversation today, we're going to be talking about malnutrition in the context of being undernourished. So, not consuming enough, having weight loss or having any sort of muscle or fat wasting in your body that could lead to basically your body's tissues and cells, all those things not being able to function properly or how it should. So that's, in a nutshell, what malnutrition is. But in terms of diagnosing it, that can get a little bit more complicated, in terms of what criteria we use to diagnose someone with malnutrition.

John Horton:

Yeah, we're going to definitely get to that here in a little bit.

How common is malnutrition? Like I said, I know it's a huge issue worldwide. How many people truly can have it that you just see walking around day to day?

Krista Mielnik:

Yeah, so you mentioned the World Health Organization earlier, and they actually do have the statistic that 1 in 3 people worldwide suffer from malnutrition.

John Horton:

Wow. That is huge, yeah.

Krista Mielnik:

Yeah, it is. And that really encompasses any nutrition imbalance. So that could be being underweight or undernourished. That could also be being overweight or obese. But again, for our conversation today, we're talking about people who are undernourished or undernutrition, and so the number might be a little bit less than that in terms of being undernourished. But in the United States, I think that malnutrition is something that people probably underestimate in terms of how many people actually suffer from it, because someone might not always look like they have malnutrition or what someone might expect someone to look like that has malnutrition. So you might not be able to just see it every day out and about. And that is why the diagnosis is so important, because someone might be suffering from it and might not even know it.

Julia Zumpano:

Krista, great points. As you mentioned, malnutrition can really be very common, and in the hospital setting, we often see it associated with a disease state. So, can you explain a little bit about maybe what disease states are a little bit more prone to malnutrition, and then what normal day-to-day environmental issues or influences may contribute to malnutrition?

Krista Mielnik:

Yeah, for sure. So with the diagnosis of malnutrition, we do take into account sort of the etiology of where it's coming from, and that kind of gives us a guide of how we want to intervene on it. So with that being said, when you're in the hospital, or I'm seeing somebody as a patient in the outpatient basis, some people who might be more at risk of having malnutrition would be anyone who maybe has a chronic illness of some kind like cancer or irritable bowel disease or maybe going through evaluation to get an organ transplant, cystic fibrosis, something like that. So any kind of chronic illness that might cause somebody to maybe burn more calories than they're able to take in or it's affecting their ability somehow to take in enough calories to maintain their weight and maintain their health. So that could be any kind of neurological diseases, anything that can cause swallowing issues, they can run the gamut.

So that's what you might see when you're in the hospital or I'm seeing a patient in the outpatient basis. In terms of someone just sort of like day-to-day life who might possibly have malnutrition, that kind of depends on the circumstances. I think that any kind of mental health disorder can cause issues with nutrition if you're not able to eat enough. Also, just generally, food insecurity. If you don't have access to enough food and you're not able to eat enough to maintain your weight, maintain your health, that can cause malnutrition.

And I think more and more now as well, we're seeing people who are maybe taking some of these weight loss medications, some of these injectable GLP-1s, who are losing a lot of weight quickly, maybe not eating enough to meet their needs sort of baseline could result in somebody being malnourished.

John Horton:

Yeah, I've also seen it listed with athletes, and that's kind of I think where it comes up to where malnutrition is referred to as an invisible condition sometimes in people. What causes it there?

Krista Mielnik:

So athletes for sure can suffer from malnutrition, and that can be from overtraining. It can be from expending more calories than you're inputting. So as much as you're training and you're working your sport, you might not be taking enough calories, protein, those things to maintain your weight, to maintain your health overall, that could definitely result in malnutrition. And also, other issues of frailty, fractures, things like that are common in people who are malnourished and also athletes.

Julia Zumpano:

We'll also see it with dementia or Alzheimer's as you age, just forgetting to eat or not consuming enough. So oftentimes, that's another red flag you want to look out for.

Krista Mielnik:

Yeah, definitely. Yeah, and also, maybe just as you age, not feeling as hungry as you did prior. So just really a lack of appetite can cause malnutrition if someone doesn't feel hungry, like you said, they can forget to eat or just not feel like eating.

John Horton:

Yeah, it seems like the big thing I take out of all that is that there are a lot of times you might not know somebody's malnourished just by looking at them in general, but there definitely are some hints that we might have, and that's where we're going to go next here with talking about how to screen for malnutrition. And I know when we were talking ahead of time, it was fascinating how you look at somebody's body and you can tell or get a good idea as to whether or not they might be malnourished. So can you walk us through, I think you called it a nutrition-focused physical exam and what goes into that?

Krista Mielnik:

Yeah, for sure. So yes, the registered dietitians do perform a nutrition-focused physical exam during any of their assessments with a patient, especially if they're triggering for potentially being malnourished.

So if they've lost weight or they are doing an interview and they can tell that someone isn't eating enough as they should, they'll definitely always perform a nutrition-focused physical exam. So that basically involves assessing a patient from head to toe and observing and palpating different areas of the body to assess for muscle and fat mass and any losses that someone might have in those areas. So just a few examples of some areas that we would target would be someone's temples, around their eyes, around their clavicle bone, muscles and their quadriceps or their calves. Those are just a few points that we hit. And then, once we assess every area that we're looking at, we then will take an average of them and determine if someone is severely, moderately or mildly wasted in fat and muscle mass.

John Horton:

Yeah. Can you describe a little more though what you're looking for, like around somebody's eyes or in their temple? What are the specific indicators that you see that go, "Wow, there might be a little some malnourishment going on"?

Krista Mielnik:

Yeah, so under the eyes around the temples, it would be any kind of hollowing, darkness, shadows, anything that's indicating that there is loss there.

John Horton:

Kind of that sunken look that sometimes you see with people?

Krista Mielnik:

Exactly, yeah. If you do picture somebody who you might think would be malnourished, and you're thinking of someone who looks emaciated, starving, that would be a severe example of muscle or fat wasting. So that's very easy to see, but dietitians are trained to assess even more milder changes in fat and muscle mass. And so yeah, somebody who is severely malnourished, you can notice that right away. But there are even signs of some of that hollowing, some of that darkness even before someone gets to the severe point.

John Horton:

And then, you had mentioned, too, around the clavicles — I take it that's just when you start seeing bones sticking out where you usually don't see bones.

Krista Mielnik:

Exactly. Yep, yep. We use our fingers and hands to palpate around the clavicle, and again, you can observe for wasting there, and is it looking very sunken in, but you can also feel the area around there and the firmness of it. And if it isn't feeling firm and sort of bouncy, for lack of a better term, you might notice that there is some wasting there. And that's where it's also important to ask the patient questions about themselves, too, and ask them, "Have you noticed changes here in your clavicle? Is this how your clavicle normally looks or do you feel like it is looking kind of more wasted than usual?" Because that's important as well. Some women might have more pronounced clavicles than men, so it's an important thing to ask along the way what the patient has noticed in their own body.

Julia Zumpano:

I was going to mention that, too. We do assess men and women slightly differently based on their fat and muscle distribution. That naturally occurs a little bit differently with men and women, as well as the importance of understanding what they looked like prior to the point where you see them. What was your normal body weight, your normal strength? Do you notice losses of muscle or fat in certain areas of your body? And then you may focus on assessing those areas greater.

Krista Mielnik:

Yes, definitely. It's always important to involve the patient in what you're doing because they know themselves best. They know what changes they've had. They know how things look, how different they might look. So yeah, it's really important to always ask them the questions as well and take them along as you're assessing them from head to toe.

John Horton:

Julia, you just mentioned the losing fat thing or whatever, you start noticing changes. As we all know, a lot of us are always trying to do that anyway. When is it a bad loss that would indicate more malnutrition as opposed to just I finally got those five pounds that have been hanging on for way too long?

Krista Mielnik:

Yeah, that's a really great question because it sort of might seem confusing, like, "Oh, if I'm losing weight, then does that mean I'm not good?" Definitely not. That's why it is such a bigger diagnostic process than people might think because there are certain criteria that go into it that aren't just related to weight. And so if somebody is losing weight intentionally, that's much different than someone losing weight unintentionally. If someone's losing weight unintentionally, that's usually a result of them not eating enough or some maybe kind of chronic illness going on that's causing them to lose weight without them trying. If someone's losing weight intentionally, that usually means that they're probably not sick enough to get to the point where they might be malnourished.

Now, with that being said, someone was losing weight intentionally on one of these weight loss medications, then we'd want to assess how much weight they lost and in what period of time because that also is meaningful. We really only count weight loss in our diagnosis if it meets certain criteria of amount in a certain period of time. So, for example, over 5% of weight loss in a month would trigger as what we would call significant weight loss, which would mean that we would want to put that into account when we're assessing for malnutrition.

John Horton:

A little bit of a red flag, it sounds like, if you drop that much that quickly.

Krista Mielnik:

Yes.

Julia Zumpano:

Right. And then, that's where the nutrition intake plays a role, too. So we're looking at how much they're consuming, if they're losing a rapid amount of weight and it's intentional, although they're not in any means meeting their nutrient needs, like Krista mentioned, if they're on one of these weight loss drugs and a common side effects is feeling nauseous or early satiety where they may just be consuming 25 to 50% of their normal intake, which is also a red flag.

John Horton:

Let's talk about some of the cosmetic things that I know you had mentioned, too, and these were really fascinating. So I think you had mentioned hair, skin, nail health. How does malnutrition show up there?

Krista Mielnik:

Yeah, so in terms of the diagnosis, the physical assessment of those areas don't count into the diagnosis, but we always do assess those areas to assess for micronutrient deficiency.

John Horton:

What, kind of bonus hints, then?

Krista Mielnik:

Exactly. Yeah.

John Horton:

OK.

Krista Mielnik:

Micronutrients would be any kind of vitamins or minerals that you might not be getting in the diet, in which case some of those deficiencies can show up physically in hair, skin, nails, mouth, eyes, things like that. If people think back to when people were coming over here on ships and they got scurvy, that's from vitamin C deficiency, so you get bleeding gums if you're not getting enough vitamin C, and so they just gave them some oranges and they solved their scurvy, but that's just an example that a lot of people know of a micro nutrient deficiency that comes up physically. So we always assess physically those areas as well to determine if we might want to do further testing to see if someone might be deficient in any of those vitamins or minerals.

John Horton:

Krista, I have to tell you, I love a scurvy reference with sailors. I mean, that's top-notch right there. Anytime we can work that into the podcast, I'm a fan.

So with the hair, does the hair just become more brittle? Does it fall out? I mean, what kind of happens there?

Krista Mielnik:

Yeah, more brittle, easily pluggable, kind of thinner, generally dull looking. Even patients who might have a rapid amount of weight loss quickly, for example, people who have bariatric surgery or something like that, losing hair is actually something that's common with really significant weight loss in a short period of time.

Julia Zumpano:

Also, checking iron levels because hair loss is a very common symptom of inadequate iron intake or inadequate stores of iron. So you could be taking it enough, but not absorbing it or storing it properly as well. So something definitely to look out for. And sometimes, big shifts in protein intake can also affect hair loss. So if you are significantly dropping the amount of protein you're consuming, that can also stimulate hair loss.

John Horton:

Well, and that's where you get into, with the whole idea of malnutrition, it could be that you're still eating a lot, but you're not eating the right things.

Krista Mielnik:

Yes, for sure. That definitely can be an issue for people, and especially if they're avoiding certain foods for some reason or they might be trying to tease out their own food sensitivities, things like that. Cutting out major things from your diet can cause some of these micronutrient deficiencies and people might not even know it.

Julia Zumpano:

Oftentimes, even our standard American diet, which we call the “sad diet,” if someone's consuming ultra-processed food, sugary sweetened beverages, and they may be consuming enough calories, but they're not consuming enough essential vitamins and minerals through good sources of their macronutrients. So they could be not getting enough high-quality carbohydrates or high-quality protein or healthy fats to meet their nutrient needs. So calorically, they could meet their goals, but not nutritionally.

Krista Mielnik:

Yeah, definitely. And I think even when they come out with the dietary guidelines, there's always these nutrients of concern that they really address that people might be missing in the typical American diet, and they go through that for young kids and adults as well. So iron is always one of those things, like that we might be missing out on in our typical American diet.

John Horton:

And that's what was so fascinating. We were talking earlier, when you mentioned how malnutrition is oftentimes an issue with people who are obese, which is not what any of us would think when you start thinking of what malnutrition might look like. And I guess, that gets to the whole notion that eating more food doesn't mean that you're eating enough quality food, so you still might be not getting the nutrients that you need, which is why you start having these issues.

Krista Mielnik:

Yeah, exactly. And that's why the term “malnutrition,” like I mentioned in the beginning, can really just mean a nutrition imbalance overall in the hospital setting or what I'm dealing with, is more of the diagnostic criteria of being undernourished. So yes, that's a little bit different than kind of malnutrition in the setting of maybe not having the right nutrients, things like that. But all or definitely a concern for any person out there who's trying to just live a healthy lifestyle.

John Horton:

Now, we were talking about how you screen for it and things you look for. And so there's two more things I wanted to make sure to hit there. And one was signs of fluid retention or dehydration, which, they seem like two opposite ends of the spectrum, though. How can they both be possible signs of malnutrition?

Krista Mielnik:

Yeah, so we definitely always assess for fluid accumulation or edema. So swelling in lower extremities, upper extremities, someone can have swelling if they're malnourished in a severe sense because our bodies go through this inflammatory process where they basically start holding on to more fluid when there's not enough protein and nutrients in the diet. So that's more in severe circumstances.

And then dehydration can come from just basically not eating enough, not drinking enough or having excessive losses in some way. Say somebody has the flu and is throwing up a lot, you're wasting all the fluid that way. So that would be why dehydration would be an issue, too. But those are the two areas that we're looking at in terms of fluid, but they tend to be in more severe circumstances.

John Horton:

And then, the other one — this one is stuck with me ever since you brought it up — it was that you look at, I guess, the fat in between your thumb and your forefinger, which just how you find anything at that little spot is beyond me, but tell us a little bit about how that is kind of an indicator.

Krista Mielnik:

Yeah. So that's actually one of the areas on the nutrition-focused physical exam that we assess. It's actually an area of muscle. It's called the interosseous muscle, and it basically involves us telling the patient to make their hands into okay signs, and then we feel this kind of little muscle right here in between, and there's actually interosseous muscles in between all of your fingers, and that can be an area that can have some wasting if you are malnourished.

Julia Zumpano:

That's an easy one to assess. That's a quick and easy one. I like that one.

Krista Mielnik:

Yeah. Especially in the outpatient setting.

Julia Zumpano:

Anything that you can see their head, shoulders or hands is a nice way to just … a quick screen to assess.

Krista Mielnik:

Yes, for sure.

John Horton:

Julia, I know when we were talking, you had mentioned that you'll see people and instantly think like, “Wow, I wonder if they're having some sort of dietary issue or if they are a little malnourished.” Is it that obvious?

Julia Zumpano:

I think it's more obvious to myself or Krista or any of the outpatient dietitians or inpatient dietitians that are doing this every single day and we're looking at screening our patients, making sure we're not missing anything. We're asking these questions on a day-to-day basis. But even if I see a family member or an elderly friend or someone I haven't seen in a long time and I notice a change, I do just naturally start to look at those areas and assess their errors and maybe even just ask them how they're doing. I don't know Krista, do you notice that with yourself, noticing those types of assessments to just general people or people in your family or friend circle?

Krista Mielnik:

Yeah, I think that it's funny you did mention that sometimes, you'll just see somebody out in the public and they'll be like, "Oh, they have some clavicle wasting," or something, which I think is just sort of like a niche dietitian thing to think. But yeah, for sure. I mean, I definitely have dietitian friends who will assess their grandparents or if they know anyone in their family who's having any kind of nutrition issue, might do a physical exam on them. So yeah, I think it's probably something that we're just attuned to because it's part of our training and we're looking at it day to day and practice as well. So yeah, it's definitely something that I noticed along the way, too.

John Horton:

It seems like half the world is always on some sort of diet at some point because we're all trying to get rid of those last couple pounds. When you start dealing with malnutrition, how often is it something that we kind of bring on ourselves, through maybe we establish some bad eating habits or patterns because we're trying to lose weight and we end up doing something that's a little harmful to our bodies?

Krista Mielnik:

Yeah, that's a really good question. I think something that is so important to talk about, because it is underestimated and I have seen it a lot in practice, and I'm sure Julia has as well, where you have these patients come in who have maybe been doing this on their own for some time and you go over their diet recall with them and talk about what they've been eating and it's unbelievable how much they're restricting, how many foods they're not having, and that might be from trying to lose weight or it can also be from people who are having any chronic GI issues or just general health issues in general.

Maybe they're looking for something in their diet that might be causing it, and so they're taking things out and limiting things and trying some of these elimination-type diets. And I can't tell you how many times I've seen people come into my office and be on these types of things on their own. I just can diagnose them with malnutrition from that. It's really not … it's not from anything that they're doing purposely. They're trying to help themselves, but they don't realize that by taking so much out of your diet, it can really do some damage.

Julia Zumpano:

I also think there's so much false nutrition information out there, unfortunately, which is really the goal of our podcast, is to be able to provide good science-backed nutrition information. But people get a little bit in a rabbit hole, so they might start to cut out one thing and then that may not improve their health outcomes, so they continue to cut out more and more and more, but they never add the other things that they cut out back. So then, all of a sudden, they may be consuming five foods and just rotating between those, not knowing what to do, hoping to get some relief from their symptoms, whether they're GI or whatever the case might be. And then, that's when you get people at a high risk for malnutrition.

John Horton:

It seems like in this, Julia, it makes me think when you talk about fad diets and sometimes the dangers with those, especially when they just kind of focus on eating one particular thing as opposed to eating a variety of foods that bring you a host of nutrients.

Julia Zumpano:

Absolutely. I mean, those very restrictive diets are what we're exactly talking about. Now, anything followed in a short term, you follow it for a day or a couple weeks, you're likely not going to stimulate any nutritional deficiencies at that point. But if you're following it for months or years at hand, then you're definitely going to put yourself at risk for nutritional deficiencies, especially if you're cutting out entire food groups and multiple food groups is even worse. So you have to think about each food group that we consume provides us different nutrients, different vitamins, different minerals — we need them all. And if you can't consume a certain food group or class of foods, then that's where a dietitian comes in to help you find the nutrients that are in that class of foods elsewhere and to be able to provide those nutrients and still be able to meet all your needs.

John Horton:

Now, Krista, you had mentioned weight loss drugs earlier, too, and that, as we know, has become just a huge thing now as more and more people are kind of going to that sort of treatment to help lose some weight and feel a little better. Is that something where you're seeing it lead to malnutrition?

Krista Mielnik:

Yeah, definitely. And I think that this is one of those cases where it's so important to make sure that you are following with a physician and being referred to a dietitian to follow you while you're on these medications because I think, to the average person, it seems pretty simple. You take this medication, it makes you want to eat less, you lose weight. But I think it can end up a little bit more complicated than that. Julia mentioned earlier some of the side effects people can have with these medications, like nausea, the early satiety, which can cause someone to just eat less overall.

Julia Zumpano:

Constipation, I see a lot of constipation, which can also limit people's intake, how comfortable they feel. So it can be a slippery slope with the medications for sure.

Krista Mielnik:

Definitely. And then you lose weight really rapidly from not eating enough and then maybe also not incorporating physical activity. All of that can lead to a lot of muscle loss, which can really lead to frailty and just being weak and weakening your immune system. And there's just so much that can happen from losing a lot of weight in a short period of time, which can happen sometimes on these medications.

Julia Zumpano:

And when you lose weight, you also lose fat, is what we're hoping to lose, but you lose muscle along with that. So when you're losing weight rapidly, you are also more prone to losing muscle more rapidly. So that's where it's very important that you follow a higher protein diet on these medications or at least meeting your protein needs, understanding what those needs are and making sure you're adequately meeting them, adequate fluid intake, adequate fiber intake — those are really essential when you're on these meds to make sure you're at your prime and maintaining the muscle and keeping those bowels regular and making sure when you're losing weight you're going to be more prone to lose fat versus breaking down your own muscle and losing muscle.

John Horton:

How quickly can malnutrition become an issue? From everything you've said, it sounds like it's a little bit on a spectrum. You could maybe slip into it a little bit if you make some minor adjustments and then it comes back as you adjust your diet, but how quickly can it get into kind of a worrisome situation where you're really harming your body?

Krista Mielnik:

Yeah, I think on the hospital side, it can be a more acute side, it can happen rapidly, I mean, within days. So that can happen really quickly, depending on what health issue you have going on. I would say for someone maybe just out in the community who suffered one of these kinds of issues, it probably would take a little bit longer, so like an extended period of time on a very limited diet. But that could also be on the other end, too, where if somebody is doing something very strict, it could happen relatively quickly. It's all based on that diagnostic criteria that I had mentioned — so how much weight are you losing and how quickly? What percentage of your needs are you actually eating? Is it under 50%? Is it under 75%? And then, those physical changes, too, will come a little bit later, but I would say probably the most quick change you're going to see is in the weight and in your intakes, and that can happen relatively quickly depending on what's going on with the person.

Julia Zumpano:

Kristen mentioned earlier that you can really depress your immune system when you're not consuming enough good nutrition. So when your immune system down, you're more prone to getting sick, and when you're sick, you're more prone to malnutrition, especially if you're extending it because your body's at a state of distress, your straight of inflammation goes up, your intake goes down even more, maybe fluid intake goes down, so it can easily snowball.

John Horton:

Do you often see more issues with this, too, on either end of the age timeline here with the very young and the very old, where if they fall a little bit behind, it just cascades quickly?

Krista Mielnik:

Yeah, definitely. I would say in the older age population, it is something that can happen relatively quickly, depending on what's going on. And also, just a natural progression of aging is having less appetite, moving less, all of which can-

Julia Zumpano:

…losing muscle mass.

Krista Mielnik:

…exactly, yeah.

Julia Zumpano:

It all comes with age.

Krista Mielnik:

Yeah. And part of our job is to tease out, too, are we dealing with malnutrition? Are we just dealing with age-related muscle loss? What's going on here and how can we intervene and fix it? Then, on the other end, with young people, it could be from a myriad of reasons, like I said, depending on what health conditions they have, mental health conditions, food insecurity, things like that. So I would say anywhere along the spectrum, it can happen quickly. But those high-risk people probably would be more of those older age people, and also young kids, babies, kids, they're followed really closely for growth and making sure they're meeting all their needs.

Julia Zumpano:

I see patients often after surgery, so that's another risk factor, is you've already gone through a surgery, your body's needs increased tremendously and you have to make an extra point to be sure you're meeting your fluid needs, your protein needs. So that's another area where they may go into surgery with a normal weight, they may have not eaten very well during their hospital stay, not felt so good when they got home, and then you're a month later and have lost a tremendous amount of weight, and muscle, and that's another big risk factor, too.

John Horton:

All right, so we've covered all the possible ways that this happens and really kind of explored that. So we know we're looking for the sunken eyes and the clavicle and I guess skinny areas in your hand, in between your thumb and your index finger, all these sorts of things. So if you have malnutrition, how do you get back on track and get things right again?

Krista Mielnik:

Yeah, so I think that that really depends on what the etiology is or what the underlying reason is for your malnutrition, which is why it is important to try and see a registered dietitian to help you tease that out. You might have gotten a diagnosis from seeing a dietitian, in which case, they will help you to address it in whatever way is most appropriate. But if you're someone who's out in the community who might think, “Oh, maybe this could be an issue for me,” it's important to see a dietitian to really accurately assess your needs and help you to meet your needs, however you need to in terms of what kind of restricted diet that you're on or any of those factors that might be at play.

John Horton:

Is it as simple as just adding food back in or if you're malnourished and you start throwing all this stuff, everything you need back in, is your body going to go, "Whoa, whoa, whoa, whoa, too much. I can't handle all this right now."?

Krista Mielnik:

Yeah, totally. I mean, again, it depends on the degree and how malnourished somebody is. Not to get too in the weeds on this, but there is something called “refeeding syndrome,” where if somebody is very, very, very malnourished, it can be dangerous to start eating just a lot of food right away. You could have basically some of the electrolytes in your body kind of tank and it can be a really dangerous situation for your heart. And so if somebody were to be extremely severely malnourished, well, it is absolutely appropriate and needed for them to be in the hospital to actually get them re-nourished. But for someone who's not as severely malnourished as that, then yes, eating more is the answer, but I think that it does end up being a little bit more complicated than that, depending on what the reason is behind your malnutrition.

If you're someone who is on one of these weight loss medications that just has not been eating enough and has lost a significant amount of weight and is feeling more weak, frail, then the dietitian can help you to again accurately assess how much you need in terms of calories and protein and then figure out real ways of real food that can help to get you there. If it's somebody who might be with [have] some kind of serious condition like cancer or something like that, then it's about working with a dietitian to meet your needs with foods that are going to fit within your treatment plan, what kind of side effects you're having, things like that. So it can be a little bit more complicated than just eat more, depending on what you have going on.

Julia Zumpano:

It's a pretty targeted approach. We do really target the reason for the malnutrition, what micronutrient deficiencies we may see, and we adjust our plan and our recommendations based on that. So it is very targeted.

John Horton:

So I take it if somebody is severely malnourished and they come in, you're going to have a blood test done and you're going to be able to see, then maybe if you are deficient in iron, like you had mentioned earlier, Julia, or some vitamin, and then it kind of helps you really target what you need to take in.

Krista Mielnik:

Yeah, yeah, for sure. And also determine, is it coming from just not eating enough? Is it coming from some of absorption issue? Are you eating enough, but you're not absorbing a certain nutrient that you need to? So all things that we can help to tease out to make sure that we're getting people's levels back within the normal range.

John Horton:

The absorption issue is one I don't think we really hit on much earlier. So tell me how that can lead to malnutrition and when you usually see it.

Krista Mielnik:

Yeah, so I would say probably the majority of the times that we see it are going to be in patients who have any kind of GI disorder. Something that a lot of people have heard of is celiac disease. So celiac disease is basically your gut reacting to gluten in the diet and it can damage the lining of your intestines and cause you to not be able to absorb certain nutrients within your GI system. So the only way to fix that is to remove gluten, heal the gut, and then you can absorb what you need to absorb. But that's a good example of someone might be eating enough or meeting their needs, but their actual intestines are not absorbing the nutrients that they need to keep all of their levels within normal limits.

John Horton:

Now, I know, Julia, you had mentioned two supplements, and let's talk about how that might fit in as a solution if somebody is dealing with malnourishment.

Julia Zumpano:

Sure. So we do use a variety of different supplements if needed. We do encourage food first, of course, especially if they can absorb it and utilize the vitamins and minerals from actual food intake. But there are a variety of different nutritional supplements. There's shakes, there's a pill form, a powder form, and various nutrients that we can and will use to support someone with malnutrition, depending on the type of malnutrition or severity of malnutrition. And we may adjust what supplement we recommend, but a lot of them are very simple, easy to digest and can be included on a regular daily basis and really help the patient progress very quickly and move forward a little faster than they may be able to do with their diet alone. And that's why we tend to encourage those two.

John Horton:

Is that something people should try to do on their own, or is that really a case where you need to be working with a registered dietitian or a healthcare provider to make sure you're getting the right stuff in?

Julia Zumpano:

I think some of them can be used safely on your own. I mean, if you're even just making a high-quality protein shake at home and you're loading it with good amounts of fruits and vegetables and extra protein, I mean, that is essentially a commercial version of, that is what we're providing people, that are vitamin and mineral fortified. So you certainly can do some of them from home, but if you're really concerned about your risk of malnutrition and what severity of malnutrition you have, that's really when you should seek the advice of a dietitian.

Krista Mielnik:

Yeah, I agree with that. And I think, too, knowing what you're actually deficient in and how deficient are you, because the dosing of what vitamin or mineral you might need might not be something that you would normally buy over the counter or have available to you without a prescription. Also, some nutrients compete for absorption in your GI tract. So if you are someone who's maybe having a really limited diet and you're like, "Oh, I'll take a multivitamin and just cover all those things I'm not getting," you are not really absorbing every single thing from that multivitamin. A lot of it you're just excreting, or some of them compete for absorption, so you might get more of one, not the other. So it is important to make sure that if you are really deficient in something, then you're seeing exactly how deficient you are and working with the healthcare provider or the registered dietitian for recommendations on how much to take, how often and things like that.

John Horton:

All right, well, let's talk about that. If somebody does suspect that they're dealing with malnutrition, what's the best process? Where do they start? How do they start getting some answers and the help they need?

Krista Mielnik:

Yeah, I think probably the easiest place to start would be to maybe speak to your primary care physician. They can always refer you to a dietitian or help you find a clinic that offers dietitians to help you. So that's probably a good place to start. I would say most insurances don't really require a referral to see a dietitian. So if you do live close to any kind of healthcare system, you can probably just call and ask if they have dietitians available, which they usually do, and you can get in to see somebody when you'd like.

John Horton:

And then, it sounds like, if there are some underlying issues, a dietitian can get you connected with a healthcare provider who might be able to help you out with those, too.

Krista Mielnik:

Definitely, yes. I would say a big part of our job for maybe these patients who are a little sicker who come to us would be to refer to more of a specialty. So if somebody comes to me and they're having a lot of GI issues and I'm working on the diet piece of it, then I'm always going to recommend that they also see a gastroenterologist to help with the other medical issues going on.

John Horton:

So there are kinds of some things up here today because we've covered a lot. What do you want people to walk away from this discussion thinking about malnutrition and how it maybe applies to their life or any people around them?

Krista Mielnik:

Yeah, I think the biggest takeaway that I would like people to have is that malnutrition can just be a little bit more complicated than you think it would be. It's not so simple as somebody just looking emaciated or starving or something like that. There's nuance to it and it really does take a trained eye and a trained clinician, like a registered dietitian, to give you the right diagnosis and to really find out what's going on underneath it that's causing it. Because that's really what guides our interventions for people is figuring out, yes, what degree of malnutrition do you have, but also, why is it happening? Because that's going to guide what changes we make, what recommendations make, how we intervene to fix the problem. So I think that I really would just encourage people to understand that malnutrition can be a little more nuanced and a little bit more complicated than you might think it would be, and that registered dietitians are really just highly trained clinicians to identify this and to make recommendations to treat it.

Julia Zumpano:

Yeah, I couldn't agree more. Just understanding that malnutrition is much of a deeper issue than most people recognize, and now knowing the signs and symptoms and knowing when to seek help and there's a ton of help out there, registered dietitians should be your first phone call for sure.

John Horton:

Well, if somebody's looking for help, they got a lot of it here today, and hopefully, some answers, and it'll send them in the right direction. So thank you both so much for just a great conversation and just sharing all this fabulous information.

Krista Mielnik:

Thank you. Thanks so much for having me.

Julia Zumpano:

Thank you.

John Horton:

So Julia, I got to say I learned more in that podcast than I ever thought I was going to get out of a chat on malnutrition.

Julia Zumpano:

I know, that stat was really surprising to me, one in three-

John Horton:

…unbelievable.

Julia Zumpano:

…have malnutrition. That even shocked me. And this is my world that I'm in. I screen patients for it every day, every time I go into work. And it's also very difficult to pinpoint even the severity or if someone's malnourished. We have set criteria, but it is really a deep-rooted and complicated issue. But if there's any risk or concern, the point here is to address it.

John Horton:

And I think we did a really nice job of getting into that and just some of the things that people should look for. I mean the whole, the sunken eyes, the clavicle — I'm still hung up on the fat in between your thumb and forefinger — but there are clues and it's just a matter of, sometimes, of listening to your body.

Julia Zumpano:

Absolutely. And that's the key, really, that we're trying to help listeners understand some cues, understand their body and understand what they can do, how they can take some ownership in their own health.

John Horton:

Well, I think we gave people a lot of tips today to determine if they have the problem and where to go to get help, and that's what this podcast is all about.

So if you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, eat well.

Speaker 4:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.