Attention to Muscle Mass Loss in Malnutrition

Guest writer: Rob van Berkel, Research dietitian and writer on nutrition and health

Attention to Muscle Mass Loss in Malnutrition

Malnutrition is an underestimated problem. It is common and has adverse consequences for health. A significant proportion of these consequences result from the loss of muscle mass. It is therefore advisable to measure muscle mass in cases of (suspected) malnutrition. This can support both diagnosis and monitoring of treatment effectiveness.

What Is Malnutrition?

Various definitions of malnutrition are in use. Internationally, the term malnutrition is preferred over undernutrition. The World Health Organization (WHO) applies a broad and general definition, whereas the European Society for Clinical Nutrition and Metabolism (ESPEN) uses a more clinical definition. In the Netherlands, the ESPEN definition is generally followed.

WHO Guidelines

The WHO definition is broad and intended for public health contexts. Malnutrition refers to deficiencies, excesses, or imbalances in energy and/or nutrient intake. Overweight and obesity are included because they involve an energy surplus. At the same time, individuals with overweight or obesity may still have deficiencies in essential nutrients, which can even occur more frequently than in individuals with normal body weight. This is likely due to the consumption of foods with high energy density but low nutrient density.

ESPEN Guidelines

The ESPEN definition focuses more on clinical settings and body composition. Malnutrition is a condition resulting from inadequate intake or absorption of nutrition, leading to changes in body composition (particularly reduced fat-free mass) and body cell mass.

Diagnosis is based on at least one of the following:

Phenotypic criteria

  • Unintentional weight loss
    5% in the past 6 months or > 10% over a period longer than 6 months

  • Low BMI
    < 20 kg/m² (< 70 years)
    < 22 kg/m² (≥ 70 years)

  • Asian populations:
    < 18.5 kg/m² (< 70 years)
    < 20 kg/m² (≥ 70 years)

  • Reduced muscle mass
    assessed using validated methods

Validated methods include DXA, BIA, ultrasound, CT, and MRI. BIA is less suitable in cases of disturbed hydration status or extreme obesity. Alternative measures include anthropometry (mid-upper arm or calf circumference). Muscle strength may serve as supportive evidence.

Etiologic criteria (at least one required)

  • Reduced nutritional intake or absorption

  • Inflammation due to trauma or acute/chronic disease

Causes of Malnutrition

Malnutrition may result from:

  • Reduced intake (swallowing problems, poor appetite, dementia)

  • Increased requirements (cancer, infection, COPD)

  • Malabsorption (coeliac disease, inflammatory bowel disease)

  • Physiological ageing

Prevalence is particularly high in hospitals, affecting up to 65% of patients.

Consequences of Muscle Loss in Malnutrition

Muscle loss mainly occurs when energy and protein intake or absorption are insufficient. Inadequate energy intake leads to the breakdown of muscle protein for fuel. Insufficient protein intake limits the availability of building blocks for muscle maintenance.

Physical

  • Reduced strength and mobility

  • Increased fall risk and fractures

  • Delayed recovery after illness, surgery, or infection

  • Increased risk of premature mortality in severe cases

Metabolic

  • Reduced respiratory muscle strength

  • Lower basal metabolic rate

  • Impaired glucose and protein metabolism

Immune system

  • Reduced immune function

  • Fewer amino acids available for antibodies and enzymes

Functional and social

  • Reduced independence

  • Lower quality of life

  • Longer hospital stays

  • Increased likelihood of institutionalization

How Can Muscle Loss Due to Malnutrition Be Reduced?

Nutrition

When intake is insufficient, increasing energy and protein consumption is the primary strategy. Specific formulas can estimate individual requirements and serve as a starting point. Despite challenges such as poor appetite, increasing intake generally improves outcomes.

Physical Activity

Appropriate physical activity can mitigate adverse effects. Both resistance and endurance training are beneficial. Resistance training stimulates muscle protein synthesis and reduces breakdown, and it enhances muscle sensitivity to dietary protein, further supporting anabolic responses.

Disease-Related Malnutrition

In diseases such as cancer, COPD, or heart failure, metabolic disturbances and inflammation may cause anabolic resistance (cachexia). Although adequate nutrition remains important, it may not be sufficient. Treatment of the underlying disease is often necessary.

Consulting a Dietitian and Measuring Muscle Mass

Consulting a dietitian and regularly assessing body composition are recommended. MRI, CT, and DXA provide the highest accuracy but are costly and time-consuming. In practice, BIA offers a suitable and accessible alternative for detecting muscle loss and monitoring treatment response.

Conclusion 

Malnutrition occurs both in the general population and in clinical settings. It involves not only body weight but also muscle mass. Low muscle mass has significant adverse health consequences. Therefore, assessing muscle mass is valuable when malnutrition is suspected.

References

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Cederholm T, Bosaeus I, Barazzoni R, et al. Diagnostic criteria for malnutrition - An ESPEN Consensus Statement. Clin Nutr. 2015;34(3):335-340.

Cederholm T, Jensen GL, Correia MITD, et al. GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community. Clin Nutr. 2019;38(1):1-9.

Fearon K, Strasser F, Anker SD, et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol. 2011;12(5):489-495.

Jensen GL, Cederholm T, Correia MITD, et al. GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community. JPEN J Parenter Enteral Nutr. 2019;43(1):32-40.

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Villareal DT, Aguirre L, Gurney AB, Waters DL, Sinacore DR, Colombo E, et al. Aerobic or Resistance Exercise, or Both, in Dieting Obese Older Adults. N Engl J Med. 2017 May 18;376(20):1943–55.

Wall BT, Snijders T, Senden JMG, Ottenbros CLP, Gijsen AP, Verdijk LB, et al. Disuse impairs the muscle protein synthetic response to protein ingestion in healthy men. J Clin Endocrinol Metab. 2013 Dec;98(12):4872–81. 87.  

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