The skeleton remains in the hospital closet.

HOSPITAL MALNUTRITION
History, Prevalance, and Treatment Worldwide

Antoinette Kruger

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Hospital Malnutrition
Introduction
Malnutrition is the condition that ensues when ones body is not being provided with an adequate consumption of nutrients. Many disease states and acute events can promote malnutrition especially in a hospital setting. This malnutrition is usually referred to cachexia which is defined as a multifactorial syndrome characterized by severe body weight, fat, and muscle loss and increased protein catabolism due to underlying disease(s) (Barker, Gout , & Crowe, 2011). Hospital malnutrition is usually a combination of cachexia and malnutrition and in this review will be referred to as hospital malnutrition or simply malnutrition. Hospital malnutrition was first recognized by the medical community in 1974 and still remains highly prevalent with international studies reporting average of 40% (Barker, Gout , & Crowe, 2011). Malnutrition has been found to have adverse effects on a patient at the cellular, physical, and psychological level. More importantly, it has been associated with an increased risk of morbidity and mortality. It also has consequences on the hospital with financial losses due to the poor recognition and documentation of a patients malnutrition. Assessment, recognition, prevention, and treatment have been very poor creating a higher prevalence and likelihood of these aforementioned complications. Nutrition risk screening using a validated tool is a simple technique to rapidly identify patients at risk of malnutrition, and provides a basis for prompt dietetic referrals (Barker, Gout , & Crowe, 2011). Thus, nutritional assessment must be made mandatory during patient admittance to leave no patient unrecognized, prevent the associated complications, and effectively reduce the occurrence of hospital malnutrition

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History
The profession of dietetics and nutrition epidemiology is relatively young, yet the role of food as being a preventive and curing aspect to ones health has been recognized since the beginning of recorded human history. Nutrition epidemiology is usually dated to 1747 (PaynePalacio & Canter, 2011, pp. 3,5). In 1877, the American Medical Association formed a committee on dietetics. In 1899, dietitian was first defined as applied to persons who specialize in the knowledge of food and can meet the demands of the medical profession for diet therapy (Payne-Palacio & Canter, 2011, p. 11). Nutritional research relevance and dietitians expertise was not given value until the dawn of World War I. The examination of 2.5 million military draftees in Great Britain in 1917 found 41% to be in poor health and unfit for duty, most commonly because of nutritional status (Payne-Palacio & Canter, 2011, p. 12). Many of the men had vitamin deficiencies or were malnourished and too weak to fight. This became a national security concern, and hundreds of dietitians were enrolled and deployed to serve overseas. The American Dietetic Association was formed in 1917 by two hospital dietitians to discuss emergency war needs, address safety and adequate food supply, and prevent nutritional deficiencies. As the 20th century continued, more and more valuable nutrition research was performed and dietitians were given a second clinical importance with the onslaught of World War II. Even with nutrition and dietitians being acknowledged as an integral part of a clinical setting since the very beginning of the twentieth century, it wasnt until 1974 that hospital malnutrition was revealed in Dr. Butterworths controversial paper, The skeleton in the hospital closet. Dr. Butterworth became interested by the repetitive nutritional disorders he was observing in his patients during hospitalization and how this affected their recovery. [His paper]
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shook the medical establishment with dramatically documented observations of what became known as hospital malnutrition (History- The Hospital Malnutrition Period). Butterworths findings inspired a dramatic paradigm shift in the nutritional support provided to patients and the abandonment of long established, detrimental hospital practices that were contributing to poor nutritional health. The paradigm shift established nutritional support teams that have proven indispensable today in a hospital healthcare team. Throughout the late 1970s and 1980s Dr. Butterworth and Dr. Weinsier continued research at the University of Alabama at Birmingham on dietary needs of medical and surgical hospitalized patients. While Dr. Phillip E. Cornwell Ph.D. and Dr. Baugh devoted a laboratory to the creation of the development of Biochemical Assessments of Nutritional Status. The results provided by this laboratory helped to unequivocally demonstrate the existence of hospital malnutrition and to convince the medical establishment of the seriousness of the problem (History- The Hospital Malnutrition Period). Following the fathers' of hospital malnutrition research, the last part of the twentieth century literature has been focused around if there remains a high prevalence of hospital malnutrition after the initial paradigm shift towards nutrition care in hospitals. The literature shows wide variations in prevalence from hospital to hospital and study to study. Based on many reports worldwide, an estimated 13% to 69% of hospitalized patients are malnourished (Theresa A. Fessler, 2008). The extreme discrepancy in prevalence in the literature is due to the dependence on the different diagnostic tools used which use different definitions of malnutrition. These variations make direct comparisons of hospitals, countries, and techniques difficult. Despite nutritional teams in place, awareness, and new medical technology, hospital malnutrition is still extremely prevalent. This has led to the current research surrounding the risks of hospital

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malnutrition on patients and hospitals; effectiveness of diagnostic tools; and rate of referral of the diagnosed to dietitians. With prevalence rates as high as 69% in studies, it has become a major concern that malnourished patients in acute settings are not identified or treated upon admittance. In a handful of countries, nutrition screening on patient admission is mandatory. In many others, such as Australia, it is not and thus creates a higher prevalence of undiagnosed hospital malnutrition.

Todays Scope and Prevalence

In 1974, Dr. Butterworth observed latrogenic malnutrition, a protein-calorie malnutrition brought on by treatments, medications, and hospitalization. Malnutrition can develop as a consequence of dietary intake, increased requirements due to a disease state, from complications of an underlying illness such as poor absorption and excessive nutrient losses, or from a combination of these aforementioned factors (Barker, Gout , & Crowe, 2011, p. 515). Patients can be malnourished at admittance, at risk of malnutrition at admittance, or become malnourished during their hospital stay. Malnutrition seen in hospital patients is usually a result of both cachexia (disease related) and malnutrition (deficiency intake of nutrients) instead of caused by malnutrition alone. Malnutrition is associated with many consequences: increased muscle loss, higher infection and complication rates, impaired wound healing, longer length of hospital stay, increased morbidity and mortality, higher treatment costs, and a depressed immune system. Serious disease states, acute events, and other social risks predispose patients to malnutrition. The degree of this risk depends on the severity of the illness. The most apparent and serious risk are illnesses which prevent oral intake of food, such as oral cancer, tumors or

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strictures in the throat, stroke, and degenerative neurological disorders which result in dysphagia (Theresa A. Fessler, 2008). Furthermore, ventilator dependent patients rely heavily on timely imitation of nutrition support. While other diseases such as COPD and cancer, result in an increased metabolic demand and patients develop cachexia and poor oral intake. Patients with GI disorders are among those who are most prone to developing malnutrition (Theresa A. Fessler, 2008). GI disorders present different degrees of malnutrition depending on how long the patient waited to seek care. GI disorders, cystic fibrosis, Cohns disease, liver disease, and gastric bypass can promote maldigestion and malabsorption of nutrients leading to hospital malnutrition and weight loss. Social risks also play a role in hospital malnutrition even in patients without illnesses that put them at risk. Appetite tends to decrease with illness because of pain, nausea, weakness, and altered mood or mental status. Also, patients can become tired of repetitive menu cycles and their new dietary restrictions. Even more importantly, their food preferences might not be met depending on their culture, background, generation, and country of origin making food consumption difficult. In 2005, a Berlin study investigated the effects of social risk factors for hospital malnutrition. The study found in age older than 60 years to be the highest risk factor. After stratification for age multivariate analysis was performed and demonstrated that independent additional risk factors were polypharmacy and malignant disease in patients less than 60 years old and polypharmacy and living alone in patients 60 years and older. Acute events can lead to at risk patients becoming malnourished. For example, patients being required to be NPO (Nill Per Os or nothing by mouth) for surgical procedures or tests can create a nutrient or energy deficiency. Delays of these tests or the need for several procedures

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can result in prolonged periods without nutrients. Furthermore, when the healthcare team decides to add nutrition therapy, it will not actually start for several days. This can be further interrupted or delayed by more procedures or tests. A common mistreated event is when physicians hold enteral nutrition (EN) for perceived high gastric residuals and intolerance of EN, but actually they are not too high. According to McClave and Snider, in the 2002 North American Summit on Aspiration in the Critically Ill Patient, EN can be continued with gastric residual volumes of up to 400 to 500 milliliters when accompanied by careful evaluation for aspiration risk and signs of GI intolerance (Theresa A. Fessler, 2008). Unfortunately, many healthcare systems, such as the University of Virginia, still consider residual volumes of 300 milliliters or more as a sign of EN intolerance contributing to hospital malnutrition. Even though hospital malnutrition was first uncovered over thirty years ago, it still remains largely prevalent and undiagnosed. It occurs worldwide and affects patients of all ages- from infants in the neonatal intensive care unit (ICU) to geriatric patients (Theresa A. Fessler, 2008). Studies show prevalence ranging from 13-69% internationally. A 1994 study showed that 40% of patients admitted into a British hospital were malnourished, and two thirds of all the patients lost weight during their hospitalization (McWhirter & Pennington, 1994). In a recent report of 740 patients in three hospitals in Denmark, 23% were determined to be at nutritional risk based on BMI, weight loss, oral intake, and disease severity; only 25% of those at risk patients received adequate nutrition during hospitalization. Only 59% of the patients were screened at admission, and of those determined to be at risk, only 47% had a nutrition care plan (Theresa A. Fessler, 2008). A 2007 Australian study to assess patients nutritional status at a private hospital reported 42% of them were malnourished and only 15% were referred to the

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dietitian (Barker, Gout , & Crowe, 2011). European, American, and South American studies show similar numbers to Australian studies. A 2006 German study, reported 27.4% of patients were malnourished with a 43 % longer hospital stay than well-nourished patients (Pirlich, et al., 2006). Obviously from the proliferate studies, this is a global health issue with poor diagnosis and documentation rates creating consequences of longer hospital stays and higher infection rates. When malnutrition is left undiagnosed or untreated in the hospital, it leads to many well documented negative consequences (Barker, Gout , & Crowe, 2011). These consequences can be separated into two main categories: consequences for the patient and consequences for the healthcare facility. Malnutrition has been documented to compromise a patient on a cellular, physical, and psychological level. At the cellular level a patients immune system is depressed creating a range of adverse effects on the bodys physiology resulting in: increased infection risk, delayed wound healing, risk of pressure ulcers, alterations in thermoregulation, and risk of impairment of renal functions. almost any nutrient deficiency, if sufficiently severe, will impair resistance to infection. Iron deficiency and protein-energy malnutrition, both highly prevalent, have the greatest public health importance in this regard (SanGiovanni, 1997). With age and long duration of illness, severe weight loss of muscle and fat mass can be consequences of malnutrition. This can lead to reduced respiratory muscle and cardiac function along with atrophy of visceral organs. It has been shown that an unintentional 15% loss of body weight causes steep reduction in muscle strength and respiratory function, while a 20% loss of body weight is associated with a 70% decrease in physical fitness, 30% decrease in muscle strength and a 3-% rise in depression (Barker, Gout , & Crowe, 2011). Other psychological effects of

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malnutrition besides depression are fatigue and apathy. These in turn delay recovery and extend convalescent time. The proliferate literature on hospital malnutrition all shows evidence that it increases the length of stay (LOS) the patient is in the hospital. A United States study looking at the impact of nutritional decline and its outcomes including LOS on adult patients hospitalized for more than 7 days found that patients who experienced a decline in nutritional status during their hospitalization had a significantly longer LOS on average of four days than well-nourished patients. A similar Australian study found an average of 5 days. (Barker, Gout , & Crowe, 2011) Another contributor to LOS of malnourished patients is their higher risk of complications. For example, one study that assessed the nutritional status of patients preoperatively found that malnourished patients had significantly higher rates of both infectious and non-infectious complications (Barker, Gout , & Crowe, 2011). This has also led to malnutrition being associated with a higher mortality rate. A multitude of studies from the United States and other countries, have verified that malnourished patients are at increased morbidity and mortality risk. (Sauer MS, RD, LD). The high prevalence rate and extensive literature on its negative clinical outcomes makes it presumptuous that it has secondary negative effects on the healthcare facility. Longer LOS and the increased complications of disease related malnourished patients puts economic stress on the facility. More staff, nursing care, treatments, medications and procedures is needed to treat malnourished patients in comparison to well-nourished patients. All these issues combined indirectly increase hospital costs associated with treating the patient, secondary to the management of their primary medical reason for admission (Barker, Gout , & Crowe, 2011). A British study estimated that nutritional treatment of undernourished hospital patients
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could save Britain two hundred and sixty-six million euro a year (Kelly, et al., 2000). Another study showed that the annual expenditure of managing medium to high risk patients for disease related malnutrition was 7.3-10.5 billion euro (Sauer MS, RD, LD). Furthermore, malnutrition can have an indirect cost in countries whose healthcare system runs as casemix. Casemix-based findings assign a Diagnosis Related Group (DRG) to patients after their discharged, and hospital reimbursement is based on the DRG. When malnutrition is documented in the patients chart as a co-morbidity or a complication, it classifies as a higher DRG and the hospital receives more reimbursement. In Melbourne in 2009, a study used SGA [Subjective Global Assessment] to diagnose malnutrition across a large hospital-based population and estimated an annualized deficit to the hospital in reimbursements of AUD 1,850,540 for undiagnosed or undocumented cases of malnutrition (Barker, Gout , & Crowe, 2011). Another similar Australian study found a loss of AUD 1,677,235 due to undiagnosed and undocumented malnutrition. A German study found a loss of thirty five thousand euros, and a United States audit found a finical loss of eighty six thousand dollars due to the failure of recognizing malnutrition. Taking the opposite approach, a similar study looked at the cost-benefit associated with nutritional intervention in patients at risk of malnutrition and found that early intervention using specialized nutritional products and frequent reviews was more cost-effective than either early intervention or frequent review alone, with an estimated saving to the health care facility of USD 1, 064 per patient (Barker, Gout , & Crowe, 2011). Obviously, there are numerous relevant motivators to implement new meaningful ways to appropriately and accurately diagnosis at risk and malnourished patients in the hospital setting.

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Problem Solved
It must be understood that disease related malnutrition is much harder to identify visually than malnutrition alone. Risk of or cachexia malnutrition will not always be visibly noticeable especially if a patient is only at risk when entering the hospital and is not yet suffering from long term malnutrition. It is also important to realize that malnutrition is exasperated in the hospital setting, thus early identification is key to treating and controlling malnutrition in a clinical setting and thus decreasing human and economic costs. At risk screening should be performed within 24 hours of admittance. Many organizations worldwide are attempting to address the issue of hospital malnutrition (Sauer MS, RD, LD). These organizations such as, the Committee of Ministers of the Council of Europe and Joint Commission on Accreditation of Healthcare Organizations in the United States, have brought attention to the importance of nutrition awareness in the hospital. These organizations along with the World Health Organization need to work together to make nutrition screening upon patient admittance a world mandate in the health profession. This only makes sense with the vast amount of research that has proven nutrition to have a significant effect on patient outcome, complications, and LOS. There is a wide array of nutrition screening tools that have been validated to identify malnutrition (Sauer MS, RD, LD). Most of these do not need specific nutrition education to conduct the assessment and identify the patient at risk of malnutrition, and thus can be used by medical staff or nurses during admittance of patients. Some are as short as two to six questions and can easily become part of procedural admittance paperwork or questions. This will insure the identification of at risk and malnourished patients for early intervention and a guaranteed reduced prevalence of hospital malnutrition. If a patient is found to be at risk, they must then be referred to the dietitian for further anthropometric assessment, intervention, and treatment.

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Registered Dietitians (RD) are nutritional experts and are more equipped to properly diagnosis, treat, and prevent malnutrition in hospitals. Yet, the importance of a patients nutritional status and mandated screening must be understood by the entire healthcare team. A seminal study in 1998 looking at screening practices of dietitians in Australian hospitals surveyed dietitians on their usual practice and perceived barriers to nutrition risk screening. Of alarm, only 5% of 124 hospitals whose dietitians participated in the survey carried out routine nutrition risk screening, as required by hospital policy (Barker, Gout , & Crowe, 2011). This demonstrates the need for an all of hospital approach so that nutrition screening is part of a patients management priorities. A 1999 UK study, showed that out of 28 identified malnourished patients only 25% were referred to the dietitian (Kelly, et al., 2000). Another study found: "Questions, measurements and notes or information about nutritional status are missing in about 50% of occasions (Sauer MS, RD, LD). This information demonstrates a lack of knowledge of nutritional relevance in other healthcare professionals. Providing nutritional support to patients identified to be at risk for developing malnutrition in addition to those that already present with altered nutrition, has the potential to decrease morbidity and mortality, improve quality of life and/or functioning, as well as decreasing length of hospital stay, use of resources, and costs of care (Sauer MS, RD, LD). Without professional treatment by a Registered Dietitian, malnourished patients are not being fully treated and are exposed to a higher risk of infections, complications, and mortality which leads to ethical questions in the face of the insurmountable research associating the two. Multiple studies show dietary advice and nutritional supplementation when appropriate to significantly affect short term weight gain and nutritional status improvement, but it is hard to unequivocally prove improvement on illness-related malnutrition because of the difficulty in
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withholding nutrition support to patients identified as malnourished in a randomized-controlled study (Barker, Gout , & Crowe, 2011). A United States study method used low-high quality nutritional care and found that hospital LOS was influenced by the degree of nutritional care received. Patients who were treated with high quality nutrition care (early intervention plus frequent use of nutrition services) averaged a 2.2 day shorter hospital LOS than patients that received medium quality nutrition care (early intervention or frequent use of nutrition services), and patients who received low quality nutrition care (late, infrequent or no use of nutrition services) had the longest averaged LOS (Smith & Smith, 1997). Providing routine risk assessment and high quality nutritional care to patients will be more cost effective for a hospital than the high economic and human cost untreated and undiagnosed malnutrition (Kelly, et al., 2000). Registered Dietitians need to become ever more an integral part of the hospital healthcare team. Physicians and nurses have very limited education in nutrition. A 2004 study surveyed 106 medical schools and found that 93% required nutrition instruction and the total contact hours only ranged from two to seventy hours. Furthermore, only 41% of schools provided the minimum twenty five hours of nutrition instruction and 18% only required ten hours or less. This is shown in practice when physicians use many outdated biochemical assessments to diagnosis malnutrition or determine if nutrition therapy is effective. Clinicians have traditionally used hepatic proteins such as albumin, prealbumin, and transferrin as markers of nutrition status; however, they are now known to be negative acute phase proteins. Serum levels of these proteins decrease in response to inflammation and physiologic stress. Failure of these levels to increase does not mean that nutrition therapy is inadequate. Despite this knowledge, some clinicians still

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misuse serum protein levels to diagnose malnutrition (Theresa A. Fessler, 2008). RDs are experts in the nutritional field including medical nutrition therapy. Their knowledge of assessing a patients nutritional risks, status, and treatments are essential to the outcome of patients suffering from or at risk of hospital malnutrition. Mandated nutritional screening followed by higher referral rates to the dietetic department is imperative to preventing hospital malnutrition.

Conclusion
Hospital malnutrition is a prevalent health concern worldwide and has detrimental effects on patient outcome and the healthcare facility. Contrary to the abundant medical advancements in the last century, the simple corrective action on a patients nutritional status is still overlooked or not seen as a medical priority. The treatment of malnutrition first requires early identification of a malnourished or at risk patient using a validated assessment tool. To ensure that patients are not being left undiagnosed this needs to be made mandatory upon admission by the healthcare accrediting bodies mentioned in this review. Once screened studies have shown the success that a high quality frequent nutrition care plan has on decreasing patient LOS, complications, and hospital costs. During the nutrition intervention careful documentation should be made to offset the financial losses that come with undocumented malnourished patients. RDs are the most qualified to prevent, recognize, and treat malnutrition in the clinical setting. RDs can also educate other health professionals in the prompt identification and monitoring of malnourished patients. These actions will make a positive impact on the healthcare system and provide better treatment to the patient. While health care costs and resource utilization are ever increasing, health care professionals should not ignore this simple method to reduce the economic and human costs of malnutritionscreen patients for malnutrition upon admission to hospitals, assess those found to be at risk, intervene with appropriate nutrition in those who can benefit,
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and monitor their progress in order to make necessary appropriate changes to the nutritional intervention (Sauer MS, RD, LD).

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Bibliography
Barker, L. A., Gout , B. S., & Crowe, T. C. (2011). Hospital Malnutriton: Prevalence, Identifiation and Impact on Patient and the Healthcare System. Internation Journal of Envionmental Research and Public Health, 514- 527. History- The Hospital Malnutrition Period. (n.d.). Retrieved November 2012, from The University of Alabama at Birmingham Department of Nutriton Sciences: http://www.uab.edu/nutrition/about/31-wendy-demark-wahnefried?start=2 Kelly, I. E., Tessier, S., Cahill, A., Morris, S. E., Crumley, A., McLaughlin, D., . . . Lean, M. (2000). Still hungry in hospital: identifying malnutriton in acute hospital admittance. Q J Med, 93- 98. Kruizenga, H. m., Van Tulder, M. W., Seidell, J. C., Thijs, A., Ader, H. J., & Van Bokhorst-de van Schueren, M. A. (2005). Effectiveness and cost-effectiveness of early screening and treatment of malnourished patient. The American Journal of Clinical Nutrtion. Matthias Pirlich, M. ,. (2005). Social risk factors for hospital malnutrition. Nutrition, 295-300. McClave, , S. A., & Snider, H. L. (2002). Clinical Use of Gastric Residual Volumes as a Monitor for Patients on Enteral Tube Feeding. Journal of Parenteral and Enteral Nutrition,, 43-48. McWhirter, J., & Pennington, C. (1994). Incidence and regonition of malnutrtion in hosptial. BMJ, 945948. Payne-Palacio, J. R., & Canter, D. D. (2011). The Profession of Dietetics: A Team Approach (4 ed.). Sudbury: Jones & Bartlett Learning. Pirlich, M., Schutz, T., Norman, K., Gastell , S., Lubke, H. J., & Bischoff, S. C. (2006). The German hospital malnutriton study. Clinical Nutriton , 563- 572. SanGiovanni, N. S. (1997). Synergism of nutrition, infection and immunity, an overview. Journal of Clinical Nutrtion, 316-321. Sauer MS, RD, LD, A. (n.d.). Hospital Malnutrition: Assessment and Intervention Methods. Retrieved from Abbott Nutritional Health Institute: www.anhi.org Smith, P. E., & Smith, A. E. (1997). High-quality nutritional interventions reduce costs. Health Finance Management, 66-69. Theresa A. Fessler, M. R. (2008, July). Malnutrition: A Serious Concern for Hospitalized Patients. Retrieved from Today's Dietitian: http://www.todaysdietitian.com/newarchives/063008p44.shtml

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