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Disease-related malnutrition in hospital and the community

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Disease-related malnutrition in hospital and the community can have a serious health impact, this article looks symptoms and treatment for this key area

Susan McLaren, PhD, RGN, is professor of nursing and director, Centre for Health and Social Care, London South Bank University

What is malnutrition?

Malnutrition is a general term used to describe under-nutrition due to inadequate food intake, dietary imbalances, deficiencies of specific nutrients and over-nutrition due to excess food consumption (Keller, 1993). More specifically, malnutrition can be defined as ‘a state in which a deficiency of energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function or clinical outcome’ (NIHCE, 2006). Disease can result in under-nutrition due to four effects; decreased dietary intakes (Table 1); impaired gastrointestinal function, which can reduce digestion, absorption and increase nutrient losses from the gut (Table 2); and altered metabolism, which changes the utilisation and disposal of nutrients (Table 3).
Chemotherapy, radiotherapy and drug-nutrient interactions can exacerbate the impact of disease on nutritional status. Table 4 summarises the non-disease related factors that can contribute to the progression of disease-related malnutrition (DRM) in hospital and community. Older adults are a known at-risk group, in whom psychosocial and economic status are contributory factors for malnutrition.

Table 1. Features and causes of decreased dietary intake

Symptoms/featuresCauses
  • Ageusia (loss of taste)

  • Oral pain (mucosititis, candidiasis)

  • Neurological injury (stroke, head injury, tumours)

  • HIV, chemotherapy

  • Anorexia (loss of appetite)

  • Nausea/vomiting may be due to underlying disease

  • Cancer, liver, renal disease, gut infection

  • Depression, anxiety

  • Dysphagia (difficulty swallowing)
  • Obstructive dysphagia (oesophageal spasm, stricture, inflammation, pharyngeal/oesophageal/ mediastinal tumours)
  • Neurogenic dysphagia (stroke, dementia, cerebral tumours, motor neurone disease, trauma)
  • Dependence on assistance (e.g. inability to perceive/ visualise/locate food, load cutlery, insert food in mouth, maintain an upright posture)
  • Neurological disorders (e.g. neurogenic dysphagia; Parkinson’s disease)

  • Arthritis

Table 2. Features and causes of impaired gastrointestinal function

Symptoms/featuresCauses
  • Decreased digestion and/or absorption of nutrients

  • Diarrhoea (enteropathies, malabsorption, infection, fistulas)

  • Steatorrhoea (pancreatic insufficiency, malabsorption, gastrojejeunocolic fistulas)

  • Variable losses of nutrients from the gut occur

  • Pancreatic insufficiency (pancreatitis, carcinoma)

  • Protein losing enteropathies (ulcerative colitis, coeliac disease, gut carcinoma, atrophic gastritis)

  • Malabsorption syndromes (Crohn’s disease, short bowel syndrome)

  • Gut infection, liver disease, fistulas

Table 3. Features and causes of altered metabolism

Symptoms/featuresCauses
  • Nutrient utilisation/disposal changed with regard to energy, nitrogen, micronutrients

  • Requirements variably increased, e.g. in proportion to injury severity

  • Defective utilisation of nutrients resulting from endocrine disorders, major organ failure, inborn errors of metabolism

  • Injury, trauma, sepsis, pressure ulcer

  • Cachexia syndrome, HIV

  • Hyperthyroidism

  • Respiratory disease associated with hyperventilation

  • Fever

  • Uncontrolled diabetes mellitus, hepatic, renal, respiratory disease

Table 4. Iatrogenic features and causes of disease-related malnutrition

ClassificationFeaturesCauses
Health professionals
  • Failure to recognise and document the problem

  • Obsolete practices relating to nutritional screening, assessment and support.

  • Unclear accountability, leadership

  • Inadequate assistance and support at meal times in hospital

  • Inadequate financial assistance and social support to purchase and prepare food in the community

  • Lack of knowledge and practical training

  • Lack of evidence-based standards and guidelines

  • Lack of specialists in clinical nutrition

  • Staff shortages; timing of meals to coincide with other events which divert staff

  • Lack of awareness of services available; resources limited

Nutrition support services in hospital and community
  • Inadequate or poorly co-ordinated services

  • Food provision adequate in hospital, but intakes poor and wastage high

  • Discontinuity in service delivery across primary and secondary care

  • Lack of management policies/organisational infrastructure for nutrition services, e.g. support teams

  • Catering systems inflexible; presentation and delivery systems poor

  • Inadequate resources and information storage and transfer systems

Prevalence

Many surveys have documented the prevalence of DRM in the UK, for example:

  • Of 500 adult acute hospital admissions, 200 (40%) were malnourished to variable extents and many deteriorated further during the course of hospitalisation (McWhirter and Penningto,n 1994);

  • Across 25 GP practices, 10% were malnourished (Edington et al, 1996);

  • In long-stay institutions and nursing homes for older adults, 16% of men and 15% of women residents were malnourished (Finch et al, 1998).

On the basis of published evidence, it has been estimated that up to 40% of patients are malnourished on hospital admission and many go undiagnosed due to inadequate screening (European Nutrition for Health Alliance, 2008).

Impact on health status

DRM results in a decrease in food intake that, if sustained over time, leads in turn to a series of changes in metabolism, body composition and function. This becomes apparent in weight loss, reduced subcutaneous fat and wasted muscle. Chronic malnutrition exerts negative, wide-ranging effects on virtually all body systems:

  • Respiration – atrophy/weakness of respiratory muscle, decreased lung volumes;

  • Circulation – degenerative changes in cardiac muscle, reduced cardiac output;

  • Haemopoiesis – anaemia, leucopenia, thrombocytopenia;

  • Gut – atrophy of the gut mucosa, decreased gastric acid production;

  • Immune system – depressed cellular and humoral immunity;

  • Skeleton – decreased bone strength/mass;

  • Skin – atrophy, local oedema, increased friability and risk of pressure ulcers;

  • Kidney – impaired filtration and excretion.

More broadly, the impact can be to increase morbidity and mortality in those whose health is already compromised by disease and its treatment. Increased vulnerability to infections, increased wound dehiscence/delayed healing, weakness and fatigue can increase rehabilitation time and costs (Green, 1999).

Preventing and treating malnutrition

A number of actions relating to the problems summarised in Box 3 could improve the detection and management of malnutrition:

  • Use of a valid, reliable screening tool to identify high-risk patients on admission to hospital or contact in primary care settings;

  • Prompt referral of high-risk patients to the dietician for further detailed assessment;

  • Referral to occupational therapist and/or physiotherapist of disabled individuals who require aids/postural supports for eating;

  • Referral to speech and language therapist of individuals with dysphagia;

  • Documenting all nutritional assessment and weekly monitoring data in the nursing care plan;

  • Consulting with patients about individual preferences for foods, portion sizes, textures and flavours, ensuring ethnic/religious needs are met;

  • Provision of skilled assistance at mealtimes to disabled individuals; use of feeding protocols can markedly improve intakes in dementia (Simmons et al, 2001);

  • Provision of an environment in institutional settings that has adequate lighting, decor, seating choice and comfort, dining surfaces that provide easy access for the disabled and handwashing facilities (Sidenvall et al, 1996).

In liaison with professional colleagues, the following are helpful:

  • Use of fortified meals and snacks that combine increased energy and nutrient density with small and/or normal portion sizes, particularly helpful where appetites are affected by illness. Waste is also reduced (Gall et al, 1998; Barton et al, 2000);

  • Monitoring of therapeutic diets;

  • Attending to food presentation, delivery, serving and accessibility of meals, for example using a decentralised, bulk food portioning approach, offering direct choice from a trolley (Shatenstein et al, 2000);

  • Development of local management policies for nutritional care, including the inception of multidisciplinary nutrition support teams;

  • Achieving best practice in nutrition support through the development and implementation of evidence-based guidelines for screening, assessment and management developed by multidisciplinary consensus – leadership and education are needed to implement these effectively;

  • Guidelines and policy recommendations which can help to achieve best practice can be found in the NICE guideline (2006); Age Concern Seven Steps to End Hospital Malnutrition (2006) and guidance published by the European Health Alliance/BAPEN/ILC partnership (2006).

References

Age Concern (2006) Seven Steps to End Hospital Malnutrition. London: Age Concern.

Barton, A.D. et al (2000) A recipe for improving food intakes in elderly hospital patients. Clinical Nutrition 19: 445-449.

Edington, J. et al (1996) Prevalence of malnutrition in patients in general practice. Clinical Nutrition 15: 60-63.

European Nutrition for Health Alliance (2008) Malnutrition. London: ENHA. european-nutrition.org

European Nutrition for Health Alliance et al (2006) Malnutrition Amongst Older People in the Community: Policy Recommendations for Change London: ENHA.

Finch, S. et al (1998) National Diet and Nutrition Survey: People Aged 65 Years and Over. London: Department of Health.

Gall, M.J. et al (1998) Effects of providing fortified meals and between meal snacks on energy and protein intakes of hospital patients. Clinical Nutrition 17: 259-264.

Green, C.J. (1999) Existence, causes and consequences of hospital and community disease related malnutrition and clinical and financial benefits of nutritional intervention. ClinicalNutrition; 18 Supplement (2): 3-28.

Keller, H.H. (1993) Malnutrition in institutionalised elderly: how and why? Journal of the American Geriatrics Society; 41: 11, 1212-1218.

McWhirter, J.P., Pennington, C.R. (1994) Incidence and recognition of malnutrition in hospital. British Medical Journal; 308: 945-948.

National Institute for Health and Clinical Excellence (2006) Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. Guideline 32. nice.org.uk

Shatenstein, B., Ferland, G. (2000) Absence of nutritional or clinical consequences of decentralised bulk food portioning in elderly nursing home residents with dementia in Montreal. Journal of the American Dietetic Association; 100: 11, 1354-1360.

Sidenvall, B. et al (1996) Cultural perspectives of meals expressed by patients in geriatric care-intentions and experiences. Journal of Advanced Nursing; 20: 613-621.

Simmons, S.F. et al (2001) Improving food intake in nursing home residents with feeding assistance: a staffing analysis. Journal of Gerontology; 56A: 12, M790-794.

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