Understanding ASPEN Malnutrition Criteria
The Academy of Nutrition and Dietetics and ASPEN malnutrition criteria is used by health professionals to identify and diagnose malnutrition.
The ASPEN malnutrition criteria can seem a bit confusing, but this article is intended to dive deep into the criteria. Making it easy to understand.
What are the ASPEN Malnutrition Criteria?
In 2012 an article was published called “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)” (1).
This article was a joint effort of the Academy of Nutrition and Dietetics (Academy) along with the American Society for Parenteral and Enteral Nutrition (ASPEN). For simplicity of this article, we will refer to these criteria as the ASPEN Malnutrition Criteria.
The purpose of this article was to create a standardized set of criteria to identify and document malnutrition. Dietitians and other healthcare professionals can use these guidelines to identify, prevent, and malnutrition in various settings.
Of note, there is a correction issued for this article. The correction is simply to clarify a reference on the estimates of adult malnutrition and not to the malnutrition criteria presented in this article.
Malnutrition Screening Tools vs. ASPEN Malnutrition Criteria
Often times there is confusion on what the difference is between malnutrition screening tools vs ASPEN malnutrition criteria.
Simply put, malnutrition screening tools are meant to identify the likelihood someone is at risk for malnutrition. While the ASPEN malnutrition criteria are meant to diagnose malnutrition.
The two often work hand in hand. A malnutrition screening tool can be used to identify a person is at risk for malnutrition. That person can then be referred to a dietitian. The dietitian can use the ASPEN malnutrition criteria to confirm whether or not this person has malnutrition.
You can learn more about malnutrition screening tools in our article, Which Malnutrition Screening Tool is Best?
APSEN Malnutrition Criteria
Malnutrition is complicated and there is no one-size-fits all approach for identification or treatment. As such, the ASPEN malnutrition criteria include 6 different characteristics for diagnosing malnutrition.
The presence of 2 of these 6 criteria meets the definition of malnutrition/
6 Characteristics of ASPEN Malnutrition Criteria (1):
- Insufficient energy intake
- Weight loss
- Loss of subcutaneous fat
- Loss of muscle mass
- Fluid accumulation
- Reduced hand-grip strength
Each of these criteria have guidelines to determine the type of malnutrition and the severity of malnutrition.
The types of malnutrition covered include malnutrition in the context of (1):
- Acute illness or injury
- Chronic illness
- Social or environmental circumstances
The type of malnutrition is important. We need to identify the root cause to establish the best interventions to stop and reverse malnutrition.
The severity of malnutrition per the ASPEN malnutrition criteria is broken down to (1):
- Non-severe (moderate) malnutrition
- Severe malnutrition
You can access the table with all of these details here.
Let’s dive into each of the 6 characteristics of the ASPEN malnutrition criteria.
Insufficient Energy Intake
The first characteristic of the ASPEN malnutrition criteria is “insufficient energy intake”. Simply put, this means an individual isn’t getting enough food to maintain their health.
All food contains varying amounts of calories. Calories provide energy. Our bodies use this energy to function- from our organs working on autopilot to getting up and walking around the house.
The more you move your body, or the more your body is working in relation to illness, injury, and healing, the more calories you need.
Each person has their own estimated energy requirement. This means how many calories they need to maintain their weight. An equal balance of calories consumed and calories used.
Dietitians use food recalls to estimate how many calories an individual is eating. This can be tricky because every day can look different with food intake.
We know those with poor appetite, get full fast, or don’t have the energy to eat are less likely to meet their daily energy needs.
Criteria Details
To meet this criterion, an individual must be at <75% estimated energy intake for non-severe malnutrition and <50% estimated energy intake for severe malnutrition.
The timeframe (I.e., How long a person has been insufficient in their energy intake) varies based on the type of malnutrition.
Energy Intake criteria:
- Acute illness or injury
- Non-severe: <75% est. energy intake > 7 days
- Severe: <50% est. energy intake ≥ 5 days
- Chronic illness
- Non-severe: <75% est. energy intake ≥ 1 month
- Severe: <50% est. energy intake ≥ 1 month
- Social or environmental circumstances
- Non-severe: <75% est. energy intake ≥ 3 months
- Severe: <50% est. energy intake ≥ 1 month
You can access the table with all of these details here.
Weight Loss
The next characteristic of the ASPEN malnutrition criteria is “weight loss”. Simply put, this means an individual is losing weight (usually without intention) over time.
Unintended weight loss often goes hand in hand with insufficient energy intake. But not always.
It is important to verify hydration levels (ex. over hydration can mask weight loss), to verify weight at baseline, and to confirm accuracy of weights.
If a weight seems extremely high or low compared to a previous weight, always double check the equipment (i.e. is the scale calibrated, was the individual standing on the scale correctly, etc.).
Criteria Details
To meet the criterion, an individual must have lost a certain percentage of weight in a specified timeframe. Keep in mind these are just guidelines. Any weight loss can be concerning.
You can access the table with all of these details here. It has the breakdown for 18 different weight loss percentages and timeframes, based on the type and severity of malnutrition.
Loss of Subcutaneous Fat
The next characteristic of the ASPEN malnutrition criteria is “subcutaneous fat loss”. Simply put, this means an individual is fat mass over time.
We all have fat throughout our bodies. It serves as a great protector for our bodies and organs.
Subcutaneous fat is the fat found just under the skin. So, if you were to gently pinch your skin, you will be squeezing your subcutaneous fat.
You may have also heard of visceral fat. This is the fat found around our organs, mostly in the stomach region.
Dietitians used something called the Nutrition Focused Physical Exam to identify fat loss. The areas we examine include the orbital area (around the eye), triceps (and biceps!), and ribs.
Criteria Details
To meet the criterion, an individual must qualify for mild, moderate, or serve fat loss, depending on the type and severity of malnutrition.
Fat Loss criteria levels:
- Acute illness or injury
- Non-severe: mild
- Severe: moderate
- Chronic illness
- Non-severe: mild
- Severe: severe
- Social or environmental circumstances
- Non-severe: mild
- Severe: severe
You can access the table with all of these details here.
Tips for Identifying Subcutaneous Fat Loss
To identify subcutaneous fat loss, the following areas should be inspected:
- orbital fat pads
- triceps
- and ribs
Keep in mind you are assessing multiple areas. And everyone may be a little different based on their genetics.
- Orbital fat pads– (area under the eyes) In a healthy person, the orbital fat pads bulge slightly. In the presence of malnutrition this area looks dark and hollow. Furthermore, this are can appear sunken in the presence of severe malnutrition.
- Ribs– (assess the lower area of the rib cage). In a healthy person, the skin will appear full with the presence of fat under the skin. In the presence of malnutrition, the ribs may become visible. The skin may appear loose in the presence of severe malnutrition.
- Triceps– (muscle in back of upper arm) Gently squeeze the skin of the triceps area, rolling the skin between your fingers. The goal is to only feel fat (and not muscle). In a healthy person you will feel a layer of fat between the skin. In the presence of malnutrition, there will be very little space between your fingers. It may even feel like your fingers can touch.
In-depth training for the Nutrition Focused Physical Exam can help in determining whether losses are mild, moderate, severe.
The Academy also has a great book with images to help called “Nutrition Focused Physical Exam Pocket Guide”. *Affiliate link. As an Amazon Associate I earn from qualifying purchases.
Informally, I like to say for each area you are assessing, there is often no question when a loss of fat is severe. If something feels off but not quite normal, that is often mild. Moderate is in-between.
Loss of Muscle Mass
The next characteristic of the ASPEN malnutrition criteria is “loss of muscle mass”. Simply put, this means an individual is losing muscle and strength- even if their weight stays the same.
When looking at muscle mass, we are looking for bilateral muscle wasting. This is the loss of muscle on both sides of the body (vs. someone who has a leg injury and just loses muscle in that area).
As with fat loss, dietitians used the Nutrition Focused Physical Exam to identify muscle loss. The areas we examine include the temples, clavicles, shoulders, interosseous (muscle between the base of the thumb and pointer finger), scapula, thigh, and calf.
Criteria Details
To meet the criterion, an individual must qualify for mild, moderate, or serve muscle loss, depending on the type and severity of malnutrition. The breakdown is the same as fat loss criteria.
Fat Loss criteria levels:
- Acute illness or injury
- Non-severe: mild
- Severe: moderate
- Chronic illness
- Non-severe: mild
- Severe: severe
- Social or environmental circumstances
- Non-severe: mild
- Severe: severe
You can access the table with all of these details here.
Tips for Identifying Muscle Loss
To identify muscle wasting the following areas should be inspected:
- Temples
- Clavicle
- Shoulders
- Interosseous
- Scapula
- Thigh
- Calf
As with the inspection of fat loss, keep in mind you are assessing multiple areas. And everyone may be a little different based on their genetics.
Additionally, lower body measures should not be used in those who are bed bound.
As a reminder, the Academy as a great book with images to help identify muscle loss called “Nutrition Focused Physical Exam Pocket Guide”. *Affiliate link. As an Amazon Associate I earn from qualifying purchases.
Fluid accumulation
The next characteristic of the ASPEN malnutrition criteria is “fluid accumulation”. Simply put, this means an individual is gaining “water weight” and this could be masking actual weight loss.
When looking for fluid accumulation, we are typically looking at the extremities (hands and feet, but mostly feet!) and the belly (ascites).
Fluid accumulation can be quite deceiving. It can look like someone is gaining weight when in fact they are becoming more malnourished.
Criteria Details
To meet the criterion, an individual must qualify for mild, moderate, or serve fluid accumulation, depending on the type and severity of malnutrition. The breakdown is the same as fat and muscle loss criteria.
Fluid Accumulation criteria levels:
- Acute illness or injury
- Non-severe: mild
- Severe: moderate
- Chronic illness
- Non-severe: mild
- Severe: severe
- Social or environmental circumstances
- Non-severe: mild
- Severe: severe
You can access the table with all of these details here.
Reduced Grip Strength
The next characteristic of the ASPEN malnutrition criteria is “reduced grip strength”. Simply put, this means an individual has a decline in functional status as measured by handgrip strength.
Handgrip strength is measured using a dynamometer. This is a tool that you squeeze and it tells you how strong your squeeze (or grip) is.
Dynamometers come with a breakdown of what normal and diminished is based on age and gender. Refer to individual manufacturer guidelines based on the dynamometer used to determine what “measurably reduced” is.
Criteria Details
To meet the criterion, an individual must qualify as having measurably reduced grip strength. This measure is only valid for severe malnutrition (and not moderate).
If you do not have access to a dynamometer, this characteristic cannot be assessed.
If you are looking to purchase a dynamometer, my personal favorite is the Jamar dynamometer. *Affiliate link. As an Amazon Associate I earn from qualifying purchases.
This was the one I used in clinical practice. It is more spendy, but it is a quality tool which will yield accurate measurements.
As with all equipment it will need to be periodically calibrated per manufacturer guidelines.
Reduced grip strength criteria:
- Acute illness or injury
- Non-severe: n/a
- Severe: measurably reduced
- Chronic illness
- Non-severe: n/a
- Severe: measurably reduced
- Social or environmental circumstances
- Non-severe: n/a
- Severe: measurably reduced
You can access the table with all of these details here.
Diagnosing Malnutrition
Using the ASPEN malnutrition criteria can help to not only identify, but diagnosis malnutrition. The presence of 2 of the 6 characteristics should be documented along with a formal malnutrition diagnosis.
The diagnosis of malnutrition is only the first step. From here, interventions (action!) needs to take place.
Referral to a Registered Dietitian is a great first step. A dietitian can individualize a plan to increase caloric intake to stop and treat malnutrition.
Conclusion: Aspen Malnutrition Criteria
I hope this article helped you to better understand the Academy and ASPEN Malnutrition Criteria. This standardized resource can help to identify the presence of malnutrition. And most importantly, it can lead to the treatment of malnutrition.