Malnutrition Assessment is an important skill of the Registered Dietitian (RD). The Nutrition Focused Physical Exam (NFPE) is part of that assessment and is a competency that is required in the 2017 standards by the Accreditation Council for Education in Nutrition and Dietetics (ACEND). I became an RD in 1995 and this was not a part of our scope of practice at that time. However, I have been with the Iowa State University Dietetic Internship (ISUDI) since 2013 where the entire RD team was trained by Cleveland Clinic so we can teach this to our dietetic undergraduate students and our ISU interns.
The NFPE is an evaluation of body systems, muscle and subcutaneous fat wasting, oral health, suck/swallow/breathe ability, skin condition, appetite and affect (1). RDs are leading the way on this hands on exam because we are the only ones looking specifically at fat and muscle loss. Accurate and comprehensive assessment leads to improved diagnosis, intervention, monitoring and evaluation. One in three hospitalized patients have malnutrition, but only 3% have diagnosed malnutrition (2). Those that are missed from diagnosis are usually those individuals in a larger body. This is primarily due to an engrained bias across many health care providers that the individual can live off of their fat stores.
However, this is incorrect information because muscle is also lost. In the presence of an acute illness and inflammation, muscle is rapidly lost and an individual even in a larger body can be in starvation mode and malnourished, which leads to poor health outcomes.
A consensus statement was jointly published in the Journal of the Academy of Nutrition and Dietetics and the Journal of Parenteral and Enteral Nutrition in 2013 (3). In addition, the Global Leadership Initiative on Malnutrition (GLIM) is another screening tool with expert consensus (ASPEN, ESPEN, FELANPE, PENSA) (4). The Academy/Aspen criteria and the GLIM criteria both represent consensus- based frameworks and are under validation testing and therefore one approach is not recommended over the other at this point in time (5).
Pictured: Alison St. Germain and two former ISU Dietetic Interns demonstrating how to perform the NFPE to Cedar Rapid and surrounding area RD preceptors. The entire Dietetic Internship Team provides these trainings annually across Iowa and have provided trainings in Ghana Africa and in Memphis TN.
Steps taken in diagnosing malnutrition
Three areas are assessed for fat loss
Eight areas are assessed for muscle loss
An example of assessment of two areas of muscle loss
Watch How to Perform an NFPE here!
The video is a production of Iowa State University Dietetic Internship and features two former Nutrition Graduate Students. The video reviews the basics of how to perform a NFPE.
Malnutrition is a Serious Condition
Spotlight on Malnutrition Month is where the Academy is raising awareness of malnutrition and the crucial role that RDs have in the nutrition care process. There are weekly webinars and a social media toolkit to help spread awareness.
Preceptors Needed to Train Interns on NFPE
The Iowa State University Dietetic Internship Team is always looking for preceptors for supervised practice of interns! We have our Iowa Based Program but also our Nationwide Program all throughout the US. We provide our preceptors with many free continuing education trainings and one of them is on malnutrition and performing the NFPE. More information on the role of preceptors and the trainings we offer can be found here https://www.dietetics.iastate.edu/preceptors
Public Policy Connection
Nutrition intervention for malnutrition can generate reimbursement dollars, reduced complication rates, decreased hospital readmission, decreased costs of care, and decreased mortality (6). However, coding, billing, and reimbursement is not seamless as is seen in the ASPEN and other Organizations Address OIC Report on Incorrect Coding of Severe Malnutrition. Cases of malnutrition in hospitals are often unrecognized due to an unstandardized process for diagnosis and treatment (7). This confusion can lead to billing errors that cause hospitals to be underpaid for the care they provide. A standardized malnutrition diagnosis system can provide more than just economic benefits, it can also bring social benefits too. The patients that show more cases of malnutrition are usually older, black, or live in lower-income or rural communities (7).
These populations will be better served by a healthcare system that addresses all cases of malnutrition. RDs have the expertise to recognize malnutrition in hospital patients and they should be permitted to identify and treat malnourished patients. This requires the trust of other healthcare professionals, reimbursement organizations like Medicare, and the general population. RDs follow a detailed process in which they must document all steps of patient care from assessment, diagnosis, intervention, monitoring, and evaluation. Using this type of nutrition-focused approach when treating malnutrition was shown to save $3,800 per patient in a recent study (8). This provides a great opportunity to decrease healthcare costs as it is estimated that 33-54% of hospital patients are malnourished but only 5-7% of them are diagnosed as malnourished. A well-nourished patient in the hospital is more likely to have a shorter stay and heal quicker. They have a better chance of going home and continuing on a smooth recovery path (9).
Academy of Nutrition and Dietetics Action Center
Action alerts are extremely important in bringing the Academy’s policy issues to the attention of members of Congress and help to raise awareness to a particular issue. It is vital that all RDs take part in this. It is easy and takes less than three minutes to do!
The Academy of Nutrition and Dietetics also has several valuable resources at
Click on “Payment” on the green bar across the top of the page to find information listed below:
1 The Academy Quality Management Committee. Academy of Nutrition and Dietetics: Scope of Practice for the Registered Dietitian. JAND. June 2013 Suppl 2 Volume 113 Number 6. http://www.andjrnl.org/article/S2212- 2672(12)01937-5/pdf
2 Tappenden KA, Quatrara B, Parkhurst ML, Malone AM, Fanjiang G, Ziegler TR. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. J Acad Nutr Diet. 2013;113(9):1219-1237.
3 White J et al. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) JPEN 2012;36(1):275-283. http://www.andjrnl.org/article/S2212-2672(12)00328-0/pdf
4 Cederholm T, et al., GLIM criteria for the diagnosis of malnutrition. A consensus report from the global clinical nutrition community, Clinical Nutrition 2018, https://doi.org/10.1016/j.clnu.2018.08.002
5 https://www.nutritioncare.org/uploadedFiles/Documents/Newsletter/GLIM%20Clarifying 20Document.pdf
6 Malnutrition, HOD Fall meeting backgrounder, 2015.
7 Weiss AJ, Fingar KR, Barrett ML, et al. Characteristics of Hospital Stays Involving Malnutrition. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. 2016. https://www.ncbi.nlm.nih.gov/books/NBK396064/
8 Electronic Clinical Quality Measures (eCQMs). Academy of Nutrition and Dietetics.
Alison St. Germain, MS, RD, LD is an Associate Clinical Professor at Iowa State University in the Food Science and Human Nutrition Department. Her private practice is Health Redefined! Nutrition for All Bodies, LLC. She is a Certified Intuitive Eating Counselor and is passionate about body respect and diversity and anti-diet weight neutral approaches to well-being
Stefanie Jensen, Iowa State Dietetic Intern is passionate about nutrition policy and public health. Upon completion of her internship, she plans to address food insecurity and improve health of vulnerable populations.