Background of malnutrition
Disease related malnutrition is a hidden epidemic, whose increasing prevalence makes it a growing issue in society today. Malnutrition prevalence is estimated from 25 % to 30 % in hospital, care homes and frail elderly.
A high prevalence
Disease related malnutrition is a hidden epidemic due to it’s increasing prevalence and is therefore a growing issue in society today. Studies estimated the risk of malnutrition:
- in hospital[4,5,6,7] : 1 in 4 patients
- in care homes[4,5,8,9,10]: 1 in 3 patients
- old person living independently : 1 in 3 persons
The cause of disease related malnutrition is often multi-factorial, resulting in insufficient dietary intake. Moreover, insufficient dietary intake can be caused by circumstances where the availability of nutrition is compromised (e.g. due to poverty, self-neglect, problems with shopping or cooking) or by circumstances where, in spite of adequate nutrition availability, reduced appetite (e.g. due to disease and its treatment, depression, cognitive problems) or problems with eating (e.g. due to ill-fitting dentures, reduced taste) result in suboptimal dietary intake.
Malnutrition has significant clinical consequences, increasing mortality, morbidity and length of hospital stay whilst decreasing the functional status. Malnourished patients may also have reduced independence, as they are also more likely to be discharged into a care home or need home care, have a higher rate of hospital admissions, GP consultations and higher prescription rates[3,12].
As well as clinical consequences, disease-related malnutrition is associated with substantial health care costs. Mean hospital costs have been reported to be more than double for malnourished compared to non-malnourished patients and the total cost of malnutrition to a health care system is measured in billions of euros per year. These extra costs can be reduced through an adequate nutritional status management of at risk patients.
Screening, diagnosis and management
An early diagnosis and management of malnutrition is advised, especially in elderly patients and the population highly at risk of frailty. Different tools can be used, individually or in combination. For instance, the Comprehensive Geriatric Assessment (CGA) provides insights in the underlying factors leading to malnutrition, whereas MUST or MNA screening scores reveal the presence of malnutrition and its causes[15,16].
Treatment of malnutrition always has two pillars:
- The treatment of underlying causes (e.g. depression, self-neglect), and
- Improvement of the nutritional status.
The nutritional support should therefore be integrated in the disease management of the underlying disease or frailty. However, some studies reveal that still less than 50% of patients identified as malnourished receive nutritional intervention[15,16].
The dietary management of malnutrition consists of nutritional support defined for each patient by a health care professional and results in either food fortification and/or Oral Nutritional Supplement (ONS), tube feeding and/or parenteral nutrition. It has been proven that in hospital and community, ONS are the most effective way to increase energy and protein intake, to improve functional capacity and clinical outcome, as well as reducing length of stay in hospital and mortality.
- Stratton R, Green C, Elia M. Disease-related malnutrition: an evidence based approach to treatment. Wallingford: CABI Publishing; 2003.
- Meijers JM, Schols JM, van Bokhorst-de van der Schueren MA, Dassen T, Janssen MA, Halfens RJ. Malnutrition prevalence in The Netherlands: results of the annual Dutch national prevalence measurement of care problems. Br J Nutr 2009; 101(3):417-423.
- Russell C, Elia M. Nutrition screening survey and audit of adults on admission to hospitals, care homes and mental health units. 2008. Redditch, BAPEN.
- Imoberdorf R, Meier R, Krebs P, Hangartner PJ, Hess B, Staubli M et al. Prevalence of undernutrition on admission to Swiss hospitals. Clin Nutr 2010; 29(1):38-41.
- Kruizenga HM, Wierdsma NJ, van Bokhorst MA, de vdS, Hollander HJ, Jonkers-Schuitema CF et al. Screening of nutritional status in The Netherlands. Clin Nutr 2003; 22(2):147-152
- Suominen MH, Sandelin E, Soini H, Pitkala KH. How well do nurses recognize malnutrition in elderly patients? Eur J Clin Nutr 2009; 63(2):292-296.
- Lelovics Z, Bozo RK, Lampek K, Figler M. Results of nutritional screening in institutionalized elderly in Hungary. Arch Gerontol Geriatr 2009; 49(1):190-196.
- Parsons EL, Stratton RJ, Elia M. An audit of the use of oral nutritional supplements in care homes in Hampshire. Proc Nutr Soc 2010; 69:E197.
- Kaiser MJ, Bauer JM, Ramsch C, Uter W, Guigoz Y, Cederholm T et al. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc 2010; 58(9):1734-1738.
- Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease related malnutrition. Clin Nutr 2008; 27(1):5-15.
- Amaral TF., Matos LC., Tavares MM., Subtil A., Martins R., Nazaré M., Sousa Pereira N. The economic impact of disease-related malnutrition at hospital admission. Clin Nutr 2007; 6:778-84.
- Elia M, Stratton R, Russell C, Green C, Pang F. (2005) The cost of disease related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. BAPEN.
- Kondrup J., Allison S.P., Elia M. , Vellas B., Plauth B. ESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003; 22(4): 415–421
- Van Asselt D.Z.B., Van Bokhorst-de van de Schueren M.A.E., Olde Rikkert M.G.M. Leidraad ondervoeding bij de geriatrische patiënt. 2010
- Loch H. et al. Introductory to the ESPEN Guidelines on Enteral Nutrition: Terminology, Definitions and General Topics. Clin Nutr 2006; 25:180–186.