Since Butterworth's call to recognize the "skeleton in the hospital closet" , focusing on iatrogenic (physician-induced) malnutrition in the United States in 1974, malnutrition has been a frequent finding in hospitalized patients. Various studies have shown that protein-energy malnutrition affects 20% to 60% of patients on general medical and surgical wards not only in the United States [4-9], but also in other industrialized countries (see Table 2.3) [10-12]. In addition, PEM has been documented in the institutionalized elderly  and patients in the community [14-15]. Some authors consider this figure to underestimate the true prevalence as some patients cannot participate in prevalence studies due to illness or extreme age . Not only are a significant number of patients malnourished on admission, a considerable number deteriorates over their hospital course [5-6, 17-18]. Thus, the question arises whether there is an iatrogenic cause to the worsening documented malnutrition, or is it simply the interrelatedness of malnutrition and disease progression? The etiology of malnutrition is complex. At-risk patients are among the most ill, and their poor nutritional status is due in part to prolonged stress responses to underlying chronic disease or hospitalization, to inadequate dietary intake, especially in elderly patients , or to a combination of these factors.
Although there is little debate that the incidence of malnutrition is high among hospitalized patients, some authors have cast doubt on whether surrogate nutritional markers, specifically hepatic proteins, truly reflect nutritional status. Seres concluded that these indicators are poorly reproducible, insensitive, and unreliable. He noted there are many different definitions of malnutrition, and its prevalence depends on how malnutrition is measured . In a review of 99 studies evaluating 12 nutritional parameters for concordance with outcomes, Koretz reported a high degree of discordance between the comparisons . Although there may be associations between decreases in these surrogate nutritional markers and adverse outcomes, Koretz concluded that nutritional markers do not predict clinical outcomes. In addition, Klein and others in a national consensus statement concurred that there is no "gold standard" for determining nutritional status and noted the difficulty of isolating the effects of malnutrition from the influence of chronic disease and the lack of reliability of nutrition parameters . Herein lies the difficulty of documenting true relationships between malnutrition and chronic disease outcomes.
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