The High Cost of Malnutrition

What does malnutrition look like? It might be different than you think. Frequently, it looks a lot like my father.

Not long ago, my dad was admitted to the hospital. In addition to having no appetite, he had lost roughly 12 percent of his body weight in recent weeks. However, because he isn’t underweight, he didn’t appear malnourished. His compromised nutritional state was overlooked.

Dad should have received a nutrition assessment and been placed on a nutrition care plan within 48 hours. Instead, he went undiagnosed and was placed on a diet of clear liquids, amounting to only a third or fourth of his required nutritional needs. Not getting the calories you need — because of illness-induced loss of appetite, gastrointestinal symptoms, restricted diets, or a reduced ability to chew or swallow — is hardly a recipe for recovery. Though Dad’s condition continued to deteriorate, it was not until day 10 of his 11-day hospital stay that he was started on nutrition intervention.

Unfortunately, this is not an isolated incident. The prevalence of malnutrition is startling and comes with an enormous economic cost – to the tune of $156.7 billion annually.[1] According to the Journal of the American Dietetic Association, one-third of patients arrive at the hospital malnourished. Another third that aren’t malnourished upon admission become so while in the hospital.[2] Left untreated, these patients continue to decline nutritionally, increasing their risk of complications and readmission. [3][4]

Undiagnosed malnutrition can lead to serious adverse events; pressure ulcers, impaired wound healing, a suppressed immune system and an increased rate of infection. Complications are also associated with a substantial mortality risk, particularly in older patients like Dad.

Many adverse reactions could be prevented with early nutrition intervention; however it is not implemented consistently. Many hospitals lack an adequate number of dietitians, who are most often tasked with nutrition care. In a survey regarding nutrition screening and assessments in the U.S., the most commonly reported barrier was insufficient staffing.[5] In addition, dietitian recommendations are only implemented by physicians in 42 percent of cases.[6] Nurses, who oversee patient care, and pharmacists, who can help with medication side effects hindering nutrition intake, are not always systematically included in the nutrition care plan.

An interdisciplinary approach can help. In a study conducted at The Johns Hopkins Hospital, a team-based approach to nutrition screening reduced the length of hospital stay by an average of 3.2 days in severely malnourished patients and resulted in substantial cost savings of $1,514 per patient.7

A comprehensive malnutrition clinical pathway leads to reduced readmission rates as well. In a community hospital that implemented such a program, thirty-day readmission rates decreased from 16.5 to 7.1 percent.8

Because I know the signs of malnutrition, I insisted on a nutrition consult for Dad. But not everyone has the information they need. That’s why the American Society of Parenteral and Enteral Nutrition (ASPEN) is committed to increasing awareness and driving progress toward early nutrition intervention through events like the upcoming Clinical Nutrition Week, offering education on every facet of nutrition support for physicians, dietitians, pharmacists, nurses, researchers, and others involved in clinical nutrition and metabolism.

Optimal nutrition is imperative to clinical outcomes; it should not be treated as an afterthought. When the proper emphasis is placed on nutrition, stories like Dad’s will become a thing of the past.

About the author:

Debra S. BenAvram, CAE, Chief Executive Officer, American Society for Parenteral and Enteral Nutrition and winner of the 2010 Women Who Advance Excellence in Associations Awards.

[1] JPEN J Parenter Enteral Nutr. 2014 Nov;38(2 Suppl):77S-85S. doi: 10.1177/0148607114550000. Epub 2014 Sep 23.

[2] Braunschweig C, Gomez S, Sheean PM. Impact of declines in nutritional status on outcomes in adult patients hospitalized for more than 7 days. J Am Diet Assoc. 2000;100:1316-1322; quiz 1323-1324.

[3] Barker LA, Gout BS, Crowe TC. Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health. 2011;8:514-527.

[4] Bistrian BR, Blackburn GL, Hallowell E, Heddle R. Protein status of general surgical patients. JAMA. 1 74;230:858-860.

[5] Patel V, Corkins R, DiMaria-Ghalili, R. Nutrition Screening and Assessment in Hospitalized Patients: A Survey of Current Practice in the United States. Nutr Clin Pract August 2014 vol. 29 no. 4 483-490

[6] Skipper A, Young M, Rotman N, Nagl H. Physicians’ implementation of dietitians’ recommendations: a study of the effectiveness of dietitians. J Am Diet Assoc. 1994;94:45-49.

7 Somanchi M, Tao X, Mullin GE. The facilitated early enteral and dietary management effectiveness trial in hospitalized patients with malnutrition. JPEN J Parenter Enteral Nutr. 2011;35:209-216.