Malnutrition includes both over-nutrition (overweight/obesity) and under-nutrition. In the context of Disease-related malnutrition, only under-nutrition is covered.
Another important note is that malnutrition is often associated with people living in countries with a shortage of normal food. Disease-related malnutrition however describes a situation in a group of patients who became, or are at risk to become, malnourished related to their disease, and for whom, very often, normally available food is not sufficient to meet their dietary requirements.
Disease-related malnutrition is widespread in the World. In Europe for example, it is estimated that 33 million people are at risk (Ljungqvist & Man, 2009). Smaller studies in other geographies show either a similar incidence of malnutrition, or most often a higher incidence. Disease-related malnutrition is also widespread across all healthcare settings in all age-groups.
• Large scale studies show that about 1 in 4 adult patients in hospital are at risk or are already malnourished (Guest, et al., 2011)
• More than 1 in 3 people in care homes are at risk of malnutrition or are already malnourished (Kaiser, et al., 2010)
• 1 in 3 older people living independently are at risk of malnutrition (Kaiser, et al., 2010)
• Almost 1 in 5 children admitted to Dutch hospitals have acute or chronic malnutrition (Hulst, Zwart, Hop, & Joosten, 2010)
Malnutrition is caused by poor food intake with disability and disease at the heart of the problem and by an increased need of certain nutrients (Khalatbari-Soltani, Mestral, & Marques-Vidal, 2019). Despite the availability of reliable screening tools, malnutrition still goes undetected and untreated in hospitals, care homes and amongst people living in elderly community settings. Even when detected, often less than 50% of patients identified as malnourished receive nutritional intervention. The opportunity for early identification and appropriate management of malnutrition or risk of malnutrition is therefore crucial to tackle the health impact it has on patients.
A key hurdle for disease-related malnutrition to be recognized as very serious is the fact that a lot of patients are overweight or obese when they become ill and their high body mass index gives a false indication that the person has no nutritional deficiencies. This is true even if the patient is losing weight and is not eating.
Disease-related malnutrition has impactful physical and psycho-social consequences such as: impaired immune response, impaired wound healing, reduced muscle strength and fatigue, inactivity, apathy, depression and self-neglect. In children, growth and development (including brain) is adversely impacted by malnutrition. Malnutrition has a particularly high adverse impact in the older person impairing function, mobility and independence. Malnutrition is also associated with poorer quality of life and a higher mortality rate.
Malnourished hospital patients experience significantly higher complication rates than well-nourished patients and the risk of infection is more than three times greater. Average length of hospital stay may be increased by 30% in malnourished patients. In elderly community patients, malnourished patients visit general practitioners more often and have more frequent hospital admissions than well-nourished patients (MNI, 2018). The extra cost of treating a patient with malnutrition is 2-3 times greater than for a non-malnourished patient. This puts a burden on the individual, the family, the society and the economy.
In Europe, the estimated cost of disease-related malnutrition is €170 billion per year. This is a conservative estimate, since the calculation was done in 2005. Since then costs in the UK already increased by more than 30% according to 2019 estimates. Failure to address risk of malnutrition appropriately puts unnecessary additional pressure on already constrained healthcare systems and leads to sub-optimal quality of care. Although the above numbers are calculations based on the European prevalence and health care costs, the model is valid worldwide. The numbers of malnourished patients in other geographies will be either similar or even higher than in Europe. A recent systematic review of studies evaluating the prevalence of malnutrition in Latin American hospitals reported that as many as 40-60% of patients exhibit evidence of malnutrition upon admission in hospital. The cost of treatment and hospital stay will differ per country but will stay significant due to the high numbers of malnourished patients. In Latin America, it is estimated that the total annual economic burden for public hospitals alone is almost €10 billion due to disease-related malnutrition (Correia, Perman, Pradelli, Omaralsaleh, & Waitzberg, 2018)
Malnutrition is mostly being detected by looking to involuntary weight loss, low food intake and a low body mass index. However, it is not just the macronutrient and with that the caloric (protein, carbohydrates and fat) intake that is important for a patient. Micronutrients are also crucial for a patient to be able to function well. Micronutrient levels will not be identified in the general screening for nutritional risk for a patient but should be taken into consideration during nutritional assessment and when planning nutritional care. For example, vitamin D levels have found to be too low in nearly 50% of independent community-dwelling older people in the UK and even in 57% of medical in-patients (Bang, Semb, Nordgaard-Lassen, & Jensen, 2009). Furthermore, 40% of older people living in institutions in the UK had a low biochemical status of riboflavin, folate and vitamin C (Finch, et al., 1998). It was also shown that 52% of older men in institutions had hemoglobin levels below the WHO cut-off for anemia and 15% had a zinc deficiency.