Malnutrition among hospital patients frequently underdiagnosed and undertreated

Malnutrition is a major contributor to multiple morbidities, decreased physical and cognitive function and impaired quality of life, as well as increased hospital readmissions and overall higher healthcare costs. A 2012 consensus statement from the Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition (ASPEN) has led efforts to improve the recognition, diagnosis and treatment of malnutrition in hospital settings. The consensus statement defined the current standard of care for assessing malnutrition based on the presence of at least two of the following clinical characteristics: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or general fluid accumulation and diminished grip strength.

In one of the largest studies of its kind, researchers at the University of Iowa evaluated close to six million adult hospitalizations at 105 institutions during 2014-2015 using a large collaborative multi-institutional database to assess the rate of malnutrition diagnoses and institutional variables associated with higher rates of malnutrition diagnosis. They determined that only 5 percent of hospitalized adult patients had medical diagnoses of malnutrition during their hospital stay. This rate was consistently low across different hospitals. The researchers found that institutional culture influences missing malnutrition diagnoses. Hospitals with higher rates of malnutrition identification had a higher volume of patients, higher hospital ranking and greater patient satisfaction.

Pediatric malnutrition is also underdiagnosed according to a team of clinicians and epidemiologists who analyzed 10 years of data from a nationally representative database of pediatric inpatient hospitalizations in the US to describe the prevalence, trends and short-term outcomes of children receiving a coded diagnosis of malnutrition. Of the 2.1 million pediatric patients hospitalized annually, more than 54,600 had coded diagnoses of malnutrition (2.6 percent). The prevalence increased from 1.9 percent in 2002 to 3.7 percent in 2011. Children with malnutrition experienced worse clinical outcomes, longer lengths of stay and increased costs of inpatient care. 

The study points to discrepancies in coding, which highlight the need for improved nutrition education and awareness among healthcare providers, as well as the integration of registered dietitian nutritionists into multi-disciplinary acute care teams. 

Physicians at the Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands, highlight the far higher rates of malnutrition among hospital patients reported in other developed countries. In these studies, a prevalence of between 6.1 percent and 11.9 percent was found for acute malnutrition (based on weight), between 7.2 percent and 10 percent for chronic malnutrition (based on height) and between 13.3 percent to 20 percent for overall malnutrition.

“The US study showed pediatric malnutrition to be associated with higher infection rates, unlike a recently published large prospective study among 14 tertiary hospitals in 12 countries in Europe, in which 2,567 children were assessed upon admission," comment Jessie M. Hulst, MD, PhD, pediatric gastroenterologist, and Koen F.M. Joosten, MD, PhD, pediatric intensive care physician. 

Malnutrition is present in 30 percent to 50 percent of hospitalized patients aged 60 or older, according to research led by Heidi J. Silver, PhD, MS, RDN, associate professor at the Vanderbilt Center for Human Nutrition at Vanderbilt University Medical Center, Nashville, TN. In contrast, only 11 percent of patients had a malnutrition diagnosis documented in the electronic health record by medical providers.

The Vanderbilt team conducted a pilot intervention to evaluate the Malnutrition Quality Improvement Initiative (MQii). This three-month intervention aimed to reduce the burden of hospital malnutrition by training and educating healthcare providers to improve screening, assessment, diagnosis and treatment for malnutrition. Participants were 45 healthcare professionals from geriatric, general medicine and general surgery units at Vanderbilt University Hospital.

This intervention significantly improved the malnutrition knowledge of the enrolled healthcare providers. It also increased the number of older patients diagnosed and treated for malnutrition as well as the number of patients whose malnutrition care was continued beyond the hospital stay into their discharge plan.

“Malnutrition in older adults most often goes unidentified, undiagnosed and untreated. This is partly due to the lack of training and education of healthcare providers in the clinical characteristics of malnutrition in today's adults, who may be overweight or obese but also malnourished,” explains Dr. Silver. 

“Unfortunately, in today's adults, being overweight or obese masks the presence of malnutrition. It is important to understand that malnutrition contributes to immune system compromise, infections, poor wound healing and development of pressure sores, physical frailty and falls and fractures,” Dr. Silver says. “By improving malnutrition knowledge, diagnosis, intervention and the timeliness of these activities, we can prevent the serious consequences and burden of malnutrition on patients, caregivers and our healthcare system.”

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