Malnutrition: causes, consequences and management
What is malnutrition?
Malnutrition is a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size, and composition) and function and clinical outcome (BAPEN). Malnutrition includes both undernutrition and overnutrition; however, this article will only focus on the issue of undernutrition.
Malnutrition, a major public health issue that often remains under-diagnosed and under-treated, especially in the community. Three million people in the UK are either malnourished or at risk of malnutrition, where 1.3 million of those are 65 years and over. According to BAPEN’s Nutrition Screening Week surveys (2007-11), 25-34% of patients who were admitted to hospitals, 30-42% of patients admitted to care homes, and 18-20% of patients admitted to mental health units are at risk of malnutrition. The medical, global, economic, and social impacts of the burden of malnutrition are still rising. Did you know how much it costs the NHS per year? £19 billion in England alone. The NHS would save £13 million a year if early diagnosis and management would have been completed, even after costs of training and screening (NICE, 2006). The management of malnutrition is not straightforward or simple, and teamwork and effort are required from various healthcare professionals involved, including dietitians, nurses, doctors, occupational therapists, speech-language therapists, family members, and pharmacists. This shows that It’s everyone’s responsibility and not one’s responsibility.
Causes and consequences
Malnutrition is a very serious yet common issue affecting millions of people in the UK. Anyone can be malnourished but some people are at higher risk due to several factors, including medical, social, and physical. Individuals with long-term health conditions such as clinical issues with digestion and absorption (inflammatory bowel disease), those who have increased nutritional requirements related to disease (COPD), or those with progressive chronic conditions (cancer or dementia) are at higher risk of being malnourished. Drugs and alcohol abuse, or simply being 65a and over, also puts you at higher risk. In addition, poverty, social isolation, difficulties in swallowing, lack of food access and availability, physical inability to eat and prepare meals, and limited mobility are other factors causing individuals to be at higher risk of malnutrition. Consequences of malnutrition include increased risk of illness complications and infection, slower wound healing, increased risk of falls, low mood, reduced energy levels, reduced muscle strength, reduced quality of life, increased hospital stay length, increased hospital readmissions, and reduced independence and ability to carry out daily activities.
MUST (malnutrition universal screening tool) is one of the most common ways to detect and screen for malnutrition. Based on weight, BMI, weight loss, and the presence of acute illness, it places individuals as being at low, medium or high risk of malnutrition. Once the risk is acknowledged, tailored advice is developed and given to the individual depending on their clinical situation. Dietitians play a huge role in the prevention and management of malnutrition, both in the hospital and community, using different management methods such as food first approach, oral nutritional supplements (ONS), enteral and parenteral nutrition, as explained below.
Food first and oral nutritional support
Providing food fortification advice to malnourished patients is the first-line approach. Food fortification, which is the idea of adding more energy and protein to the foods to make them more caloric and nutrient-dense, is achieved by several methods. For example, adding full-fat cream to soups and sauces and grated cheese to meals will make the soups/meals more energy-dense. Besides food fortification, other food-based advice such as eating little and often, employing various eating strategies to deal with taste changes, opting for high energy and protein snacks, and foods such as full-fat yogurts, creams, milk, and nuts are recommended.
The second line approach would be the use of ONS. ONS can come in several forms: liquid form or powder form mixed with water or milk, providing macronutrients (protein, carbohydrates, fat) and micronutrients (vitamins and minerals). Some ONS products may also come in different flavors and textures (e.g. yogurt style or jelly), depending on the manufacturer. There are several companies that produce ONS, where the most common ones in the UK are Nutricia, Abbott, and Aymes. The role of ONS is to complement nutritional intake when dietary changes are not enough on their own to meet the individual’s nutritional requirements. It was shown that providing nutritional supplements to malnourished patients reduces complications such as wound breakdown by 70% and death by 40% (BAPEN). It is important to be aware and acknowledge that ONS is complementary to oral intake and should not be used as a sole source of nutrition. This is because not all ONS are nutritionally complete. ONS are widely used in the community and hospitals and are prescribed, managed, and monitored by dietitians. You might also find some ONS products to purchase over the counter. Any ONS prescription is informed by an individualized dietetic assessment, taking into consideration the individual’s nutritional requirements, deficits, texture recommendation (in accordance with speech and language therapist’s advice), and product type and taste preferences.
Enteral nutrition (tube feeding)
But nutrition support goes far beyond oral nutrition support strategies (i.e. food first and supplement drinks described above). In certain situations, when nutritional requirements cannot be met by eating or drinking, artificial feeds specially formulated to provide the right balance of fats, proteins, carbohydrates, vitamins, and minerals can be delivered straight into the gut via a tube (colloquially called “tube feeding”).
Most common reasons for requiring this kind of nutrition include difficulties swallowing e.g. after a stroke or due to a neurological condition, certain operations and treatments to neck, throat, or stomach, as well as simply not being able to eat/drink enough e.g. when in hospital, despite oral supplementation.
Enteral feeding can be used short-term, to bridge the gap between intake and requirements when expecting the barriers to eating to resolve, e.g. in some cases swallowing difficulties acutely after a stroke. It can also be used long-term when the patient’s ability to eat will not recover quickly or may not recover at all. There are multiple types of tubes that can be used to provide enteral nutrition, most commonly nasogastric (going through the nose into the stomach) or nasojejunal (through the nose to the small bowel surpassing the stomach). For long-term feeding, the tube is usually inserted straight through the abdominal wall into the stomach or further into the intestine (gastrostomy, with a name varying depending on the way of insertion and tube type).
The role of dietitians in tube feeding is apparent at each stage of the process. It starts as early as advising on whether tube feeding is appropriate and what type is most suitable, all the way through deciding what goes through the tube, at what rate and in what quantity, and monitoring the patient’s tolerance to feeding. When tube feeding is used long-term, specially trained dietitians work with patients at home, to ensure the nutrition provided continues to meet patients’ needs, responding to any changes in clinical condition and feed tolerance.
Parenteral nutrition
When a patient’s gut is inaccessible for a variety of reasons, e.g. due to a blockage, perforation, when a large portion of it has been removed, or when parts of the bowel are diseased and not able to absorb nutrients properly, nutrition must be delivered straight into the bloodstream. Similar to tube feeding, parenteral nutrition may be needed either short or long-term. Due to the complexity of this form of feeding and the potential risks, multiple members of the MDT (multidisciplinary team) need to be involved at different stages of the process, including dietitians, nutrition nurses, pharmacists, and doctors.
Each hospital and NHS trust have their own protocols of escalating the forms of nutrition support. As a general rule of thumb, less invasive procedures are preferential if clinically possible. Hence, food first strategies are normally the first line of treatment, followed by nutritional drinks, then enteral feeding if the gut is working, and ultimately parenteral nutrition if the former is not possible. In reality, more than one type of nutrition support is often used, e.g. tube-fed patients may still be encouraged to continue with oral nutrition support, especially in the weaning stages, i.e. when tube feeding is gradually phased out.
The importance of person-centered care in malnutrition management
Regardless of the form of nutrition support, it is crucial that the person is put first and at the center of our intervention. This means not only considering their condition and what is clinically most suitable but also their preferences, lifestyle, and barriers to compliance. In practice it may involve adjusting food first advice to cultural differences, choosing the most acceptable ONS type, and providing suitable recipes. In the case of enteral feeding, it may be explaining to the patient and letting them have a say on whether they would prefer continuous or bolus way of feeding, or considering whether a person is capable of doing it themselves or whether they need carers. After all, with all the clinical expertise we can provide as dietitians, our patients are still the experts in their bodies and lived experiences.
Where to learn more?
We are very aware that this has been just a snapshot of the complex topic of malnutrition and nutrition support. If it sparked your interest, make sure to check out:
BAPEN: https://www.bapen.org.uk/resources-and-education/tools/23-about-malnutrition
BDA Malnutrition Fact Sheet: https://www.bda.uk.com/resource/malnutrition.html
Malnutrition Task Force: https://www.malnutritiontaskforce.org.uk/resources
Malnutrition Pathway: https://www.malnutritionpathway.co.uk/mal-overview