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UNDERNUTRITION AND CLINICAL NUTRITION

Malnutrition and What’s new?


undernutrition C NICE guidance on nutrition support in adults
John Saunders
C Detailed nationwide BAPEN survey assessing nutritional status
of hospital admissions revealed the extent of the problem
Trevor Smith C The high estimated financial cost of malnutrition has focused
Mike Stroud political attention on addressing the problem of malnutrition
C Objectives for Nutrition in Undergraduate Medical Training
(ICGN/Academy of Royal Medical Colleges)

Abstract
The term malnutrition is used to describe a deficiency, excess or imbal- In the UK, malnutrition remains an under-recognized problem
ance of a wide range of nutrients, resulting in measurable adverse effects facing patients, clinicians and the wider society. It is not only very
on body composition, function and clinical outcome.1 As such it can refer common in hospital and institutional care settings but is widespread
to individuals who are either over- or under-nourished although it is in the community. It is both a consequence and a cause of disease.
frequently used synonymously with undernutrition, as is the case in Approximately 2% of the UK population are underweight e defined
this article. Although it is well known that malnutrition is common as a body mass index (BMI) below 18.5 kg/m2 e but this is an
in the developing world, the fact that significant malnourishment occurs underestimate of malnutrition, since those who unintentionally lose
in UK society and health settings is not widely appreciated. Malnutrition weight from a position of relative excess may also be at risk what-
occurs for psychosocial reasons and as a consequence of disease. It has ever their BMI. The prevalence of malnutrition in the free-living
direct effects on clinical outcomes and is associated with massive health- elderly or those with chronic diseases increases at least two-fold and
care expenditure. Recognition and treatment can have a significant individuals in institutional care have a prevalence of malnutrition
impact on patient care and can reduce costs. Failure to diagnose and between 30 and 42%.4
manage carries medico-legal risks. It is the responsibility of all doctors UK hospital patients with malnutrition are particularly likely to be
to recognize the fundamental importance of proper nutritional care to malnourished for reasons summarized in Table 1. In a large national
good clinical practice.2 The focus of this article is predominantly con- survey conducted in 2008, 28% of patients admitted in hospital were
cerned with malnutrition and its consequences in the UK. at risk as indicated by a high score on the MUST screening tool. The
prevalence was particularly high in specific sub-populations (e.g.
Keywords clinical outcome; health economics; malnutrition; MUST 34% of all emergency admissions and 52% of admissions from care
score; re-feeding syndrome; screening

Causes of malnutrition and further deterioration in


nutritional status among hospital in-patients
The term malnutrition is used to describe a deficiency, excess or
imbalance of a wide range of nutrients, resulting in measurable Medical causes of C Anorexia of disease
adverse effects on body composition, function and clinical inadequate and/or C Nausea and vomiting
outcome.1 It is the responsibility of all doctors to recognize the poor’quality oral intake C Gastrointestinal dysfunction
importance of proper nutritional care to good clinical practice.2 C Reduced absorption of macro-
Worldwide, more than 3.5 million mothers and children under 5 and/or micro-nutrients
die unnecessarily each year owing to malnutrition,3 and around C Increased nutrient loses
178 million children have stunted growth. Micronutrient defi- C ‘Nil by mouth’ for investigation
ciencies affect huge numbers; iodine deficiency alone is thought or medical reasons
to affect about 2 billion people. C Physical disability and inability
to feed self

John Saunders MRCP is a Research Fellow in Clinical Nutrition at the Environmental causes of C Inadequate food quality
Institute of Human Nutrition and a Specialist Registrar in inadequate and/or poor’ C Inadequate food availability
Gastroenterology at Southampton University Hospital, Southampton, quality oral intake C No protected meal times
UK. Competing interests: none declared.
C Inadequate training and
knowledge of medical and
Trevor Smith MRCP is a Consultant in Clinical Nutrition and Gastroenterology nursing staff
at the Institute of Human Nutrition and Southampton University Hospital, Altered requirements C In critical illness there are altered
Southampton, UK. Competing interests: none declared. substrate demands and several
sub-groups of patients have a
Mike Stroud BSc MD DSci FRCP is a Consultant Gastroenterologist and increased energy expenditure
Senior Lecturer in Medicine and Nutrition at the Institute of Human (see below)
Nutrition and Southampton University Hospital, Southampton, UK.
Competing interests: none declared. Table 1

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UNDERNUTRITION AND CLINICAL NUTRITION

homes).4 Many patients also see a further decline in their nutritional early recurrence of the precipitate illness, e.g. in patients with
status during their hospital admission, which can then increase their chronic obstructive pulmonary disease (COPD).
risk of complications and length of stay. Although for many years it was thought that increased energy
expenditure was predominantly responsible for disease-related
Micronutrient deficiencies: in the UK, specific micronutrient defi- malnutrition, there is now clear evidence that in many disease states
ciencies are also surprisingly common, especially in the elderly. total energy expenditure is actually less than that measured in
Folate deficiency has been described in 29% of independent adults normal health. The basal hypermetabolism of disease is offset by
over 65 years old and 35% of those in institutions, while vitamin C a reduction in physical activity, with studies in intensive care
deficiency affects 40% of those in institutional care.5 patients demonstrating that energy expenditure is usually below
2000 kcal/day.8 Weight loss in patients with persistent inflammation
Causes of malnutrition or neoplasia may be accompanied by altered demands for specific
amino acids in disease states. The body meets these needs by
Although a proportion of malnutrition in developed countries is
drawing on its reserves, with excess lean tissue wasting. This may be
associated with poverty, social isolation and substance misuse,
evident as cachexia in a thin patient, but loss of lean tissue (sac-
exacerbating the health inequalities in vulnerable populations,
rcopenia) can be more difficult to detect in an overweight patient.
most adult malnutrition in the UK is associated with disease,
arising from several sources (Figure 1).
Consequences of malnutrition
Reduced dietary intake is probably the single most important
aetiological factor in disease-related malnutrition. This can be the Malnutrition affects the function and recovery of every organ
result of many psychosocial conditions, importantly including system (see Figure 2).
age, depression, and dementia. During illness there is commonly
reduction in appetite sensation owing to modified secretion of Muscle and bone: weight loss caused by depletion of fat and muscle
cytokines, glucocorticoids, peptides, insulin and insulin-like mass, including organ mass, is often the most obvious clinical sign
growth factors.6 In hospital in-patients, these problems may be of malnutrition. The visible loss of lean tissue is often described as
compounded by failure to provide regular nutritious meals, to cachexia and may be hidden in obese patients. Muscle function
protect them from routine clinical activities, and to offer help and declines before changes in muscle mass occur, suggesting that
support with feeding when required.7 Among patients under- altered nutrient intake has an important functional impact inde-
going abdominal surgical procedures, varying degrees of intes- pendent of the effects on muscle mass; similarly, improvements in
tinal failure (whether short-term or more sustained) add further muscle function with nutrition support occur more rapidly than can
nutritional risks. While there is usually a rebound of appetite be accounted for by replacement of muscle mass alone.9 Bone mass
after recovery, to restore lost weight and functional capacity, this is lost during weight loss and specifically when intakes of calcium,
response is suppressed by continued inflammation, or by the

Effects of malnutrition
Causes of malnutrition • Psychology:
• Ventilation: depression/
Altered nutrient Inadequate intake loss of muscle apathy
processing • Poor diet and hypoxic
• Increased/altered • Poor appetite responses
• Reduced cardiac
metabolic demands • Pain/nausea with output
• Liver dysfunction food
• Impaired liver
• Dysphagia
function and fatty
• Depression
change/necrosis
• Unconsciousness
• Impaired renal
function
• Impaired gut
intregrity and
Excess losses
immunity
• Vomiting
• NG tube
• Reduced
drainage • Decreased strength
• Diarrhoea immunity and
• Surgical resistance to
drains infection
• Fistulae
• Stomas
Malabsorption • Impaired • Hypothermia
• Pathology of stomach, wound healing
intestine, pancreas
and liver

Figure 1 Figure 2

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UNDERNUTRITION AND CLINICAL NUTRITION

magnesium and/or vitamin D are insufficient. Bones are slow to re- Re-feeding syndrome describes the potentially life-threatening
form during recovery, and fracture risk is high. consequences that can occur as a result of acute micronutrient
deficiencies, fluid and electrolyte imbalance and organ dysfunc-
Cardiovascular and respiratory: a reduction in cardiac muscle mass tion caused by administration of unbalanced or over-rapid
is recognized in malnourished individuals. The resulting decrease in nutritional support in patients at risk (see Table 2). Patients
cardiac output has a corresponding impact on renal function by particularly at risk are those with little or no oral intake for
reducing renal perfusion and glomerular filtration rate. Micronutrient protracted periods and those who are severely malnourished (see
(e.g. thiamine) and electrolyte deficiencies may also affect cardiac Table 3). Patients with limited nutritional intake, altered meta-
function, particularly during re-feeding. Poor diaphragmatic and bolic demands and/or increased losses undergo reductive adap-
respiratory muscle function reduces cough pressure and expectora- tation and, as a result are deficient in vitamins, trace elements
tion of secretions, delaying recovery from respiratory tract infections. and electrolytes. There is a whole body and intracellular deple-
tion of potassium, magnesium and phosphate, and a consequen-
Gastrointestinal: adequate nutrition is important for preserving tial increase in intracellular sodium and water. There is also
gastrointestinal function; chronic malnutrition results in changes in a switch away from carbohydrate to lipid metabolism as the
pancreatic exocrine function, intestinal blood flow, villous archi- predominant source of energy. The provision of nutrients will
tecture and intestinal permeability. Loss of digestive enzymes reverse these changes but administration that is either too rapid
occurs early with dietary energy restriction and commonly leads to or in an unbalanced form can result in dangerous shifts in elec-
secondary lactose intolerance, with diarrhoea. The colon loses its trolytes and precipitate deficiencies in micronutrients. Patients
ability to reabsorb water and electrolytes, and secretion of ions and most at risk are those receiving enteral tube feeding or parenteral
fluid occurs in the small and large bowel. This may result in diar- nutrition, but care should also be taken with oral nutritional
rhoea, which is associated with a high mortality rate in severely supplements. The National Institute for Health and Clinical
malnourished patients. Excellence (NICE) has specific guidance for managing these
complex patients.12 An intercollegiate working group, MARSI-
Immunity and tissue repair: immune function is suppressed early
PAN (Management of Really Sick Patients with Anorexia Nerv-
with underfeeding as a result of impaired cell-mediated immunity
osa), has produced guidelines on the medical and psychiatric
and cytokine, complement and phagocyte function, and this
management of patients with anorexia nervosa.13
increases the risk of infection. Delayed wound healing is also well
described in malnourished surgical patients.10 Malnourished
Assessment of nutritional status and diagnosis of malnutrition
patients are at particular risk from respiratory tract infections, and
any bacterial or parasitic infection is liable to progress rapidly. Nutritional status is a composite concept, incorporating dietary
Fever, and usual markers of acute inflammation (WBC, CRP) may intake (what we eat), body composition (what we are) and
be suppressed in malnutrition, so early antibiotics may be advised. functional capacity (what we can do). Information is needed
about all these components.
Endocrine: most endocrine functions are suppressed by malnu-
trition. Specifically, T4 and T3 are reduced, while reverse T3 Screening
rises. Thyroid-stimulating hormone is usually normal, unless Identification of patients at risk of malnutrition at an early stage
iodine status is impaired. Gonadotrophins are suppressed, and of hospital admission, or during attendance at the outpatient
testerone and oestrogen/progesterone all fall. Amenorrhoea is
usual. Insulin secretion is reduced, but insulin sensitivity rises
during undernutrition, so blood glucose remains low-normal. Clinical features of classical re-feeding syndrome
Hypoglycaemia is a very late pre-terminal development but may
also indicate occult sepsis. During re-feeding, insulin resistance Cardiovascular Cardiac failure
may result in a form of ‘malnutrition-related diabetes’. Pulmonary oedema
Dysrhythmias
Psychological: in addition to these physical consequences, Peripheral oedema
malnutrition also results in psychosocial effects, such as apathy,
Electrolyte disturbance Hypophosphataemia
depression, anxiety and self-neglect.
Hypokalaemia
Hypomagnesaemia (rarely hypocalcaemia)
Reductive adaptation: a down-regulation of energy-dependent
cellular membrane pumping (Na/K-ATPase) and other basic Metabolic Hyperglycaemia
cellular metabolic functions, is one explanation for the conse-
Neurological Wernicke’s encephalopathy
quences of malnutrition. In complete starvation, the process
Confusion
begins very early. It is less striking when dietary intake is simply
Seizures
insufficient to meet requirements and the body has time to draw on
its functional tissue reserves within muscle, adipose tissue and Hepatological Abnormalities in liver function
bone, although this then leads to detrimental changes in body
Musculoskeletal Rhabdomyolysis
composition. Both reductive adaptation and tissue wasting have
direct consequences on tissue function, with loss of functional Haematological Bone marrow dysfunction
capacity and a potentially brittle metabolic state. Rapid decom-
pensation occurs with insults such as infection and trauma.11 Table 2

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UNDERNUTRITION AND CLINICAL NUTRITION

 Are there any physical, medical, psychiatric or treatment


Criteria for determining patients at high risk of limitations that prevent patients meeting their requirements and
developing re-feeding problems12 lead to weight loss?
 Does the patient have particularly high requirements for
The patient has one or C BMI less than 16 kg/m2 certain nutrients (e.g. burns patients)?
more of the following C Unintentional weight loss of greater  Does the patient have excessive nutrient losses, e.g. persistent
than 15% within the last 3e6 months diarrhoea or enterocutaneous fistulae? Chronic pancreatitis can
C Little/no nutritional intake for more cause malabsorption without steatorrhoea.
than 10 days  Psychosocial history (e.g. recent social stress, social isolation,
C Low levels of potassium, phosphate previous eating disorders, alcohol consumption, prescription or
or magnesium prior to feeding recreational drugs).
The patient has two or C BMI <18.5 kg/m2 Examination
more of the following C Unintentional weight loss of greater A focused examination should include:
than 10% within the last 3e6 months  weight and BMI
C Little/no nutritional intake for more  muscle wasting (e.g. appearance of temporalis)
than 5 days  general condition of skin: fragile or dry
C History of alcohol abuse or drugs  general condition of mouth; presence of angular cheilitis and
including insulin, chemotherapy, mouth ulcers
antacids or diuretics  hydration status
 assessment of oedema.
Table 3
Investigations
Most biochemical nutrient measures are acute-phase reactants, so
clinic, is a screening step to determine which patients need
difficult to interpret. There are no specific laboratory tests to
formal assessment of nutritional status by a qualified trained
‘diagnose malnutrition’. Blood tests can diagnose some specific
person, with a view to early intervention with nutritional
nutrient deficiencies (e.g. iron, folate, B12), provide supportive
therapy. The Malnutrition Universal Screening Tool (MUST) is
information for monitoring and assessing specific electrolytes e.g.
a simple, rapid and easy method to screen patients and has been
magnesium. Low serum albumin is still commonly listed as an
shown to be reliable and valid.14 It aims to identify those at risk
indicator of malnutrition. Simple starvation does not suppress
by incorporating simple information which is collected routinely
serum albumin, but the presence of infection, or another inflam-
for other reasons:
matory process reduces albumin more than in a well-nourished
 current weight and height (BMI)
patient. Low serum albumin thus usually implies reduced
 history of recent unintentional weight loss
synthetic capacity in the liver, which cannot be corrected by
 likelihood of future weight loss.
increased protein or aminoacid supply. Bedside tests (e.g. mid-
Figure 3 provides a guide for using MUST e the total score has been
arm muscle circumference, hand-grip strength and indirect calo-
shown to be a better predictor of outcome than scores from the indi-
rimetry) can be useful aids but are usually reserved for clinical
vidual components used in isolation, and identifies most patients who
studies or departments with specialist interests, owing to the costs
have malnutrition.
of equipment, expertise required and time involved.
The screening process identifies patients who require a more
The diagnosis of malnutrition is very important. It must be
detailed assessment, and formulation of an individualized stepwise
documented together with a management plan, coded and
management plan by a nutrition specialist. Re-screening of in-patients
included in discharge letters.
at 7-day intervals throughout a hospital admission alerts clinicians to
those who have lost weight and require greater intervention.
Management
Detailed nutritional assessment All hospitals should have an established multidisciplinary
Full nutritional assessment to diagnose malnutrition is based on nutrition support team for managing patients with complex
mainly history and examination, with rather less emphasis on labo- nutritional problems. Within each organization there should also
ratory investigations than is usual for most diagnostic processes. be a nutrition steering committee to develop policies for nutri-
tional care, which should be regularly audited as part of clinical
Medical history governance frameworks.12
 Normal and varied recent dietary intake; an overview of daily Individual patients’ needs vary enormously, depending on
food intake, pattern of meals and portion size. Food their circumstances. The aim of nutrition support is to ensure
intolerance, allergies, religious or other restrictions. Specialist die- that total nutrient intake provides enough energy, protein, fluid
tetic input is appropriate in patients where concern has been raised. and micronutrients to meet the patients’ needs. In practice, the
 History of recent intentional or unintentional weight loss. majority of patients are managed by clinicians, nursing staff,
Weight loss in obesity or in patients with oedema can be more ward catering staff and dietitians, with more complex patients
challenging to assess. having input from nutrition support teams.
 Is the patient able to eat, swallow, digest and absorb sufficient In vulnerable patient groups the simple provision of regular
amounts of food to meet their requirements? meals or food with better nutritional content may be enough to

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UNDERNUTRITION AND CLINICAL NUTRITION

The Malnutrition Universal Screening Tool (MUST)

STEP 1 STEP 2 STEP 3


BMI score Weight loss score Acute disease effect score

BMI kg/m2 Score Unplanned weight loss in past If patient is acutely ill and there has
>20 (>30 obese) –0 3–6 months been, or is likely to be, no nutritional
18.5–20 –1 >20 (>30 obese) –0 intake for >5 days
<18.5 –2 18.5–20 –1 Score 2
<18.5 –2

STEP 4
Overall risk of malnutrition

Add scores together to calculate overall risk of malnutrition


Score 0: Low risk Score 1: Medium risk Score 2 or more: High risk

STEP 5
Management guidelines

0 1 2 or more
Low risk Medium risk High risk
Routine clinical care Observe Treat*
• Repeat screening: • Document dietary intake for 3 days if • Refer to dietitian, nutritional
Hospital, weekly; subject
1995 in hospital
1997 or care home
1999 2001 2003 support team or implement local
Care homes, monthly; • If improved or adequate intake – little policy
Community, annually clinical; if not improvement – clinical • Improve and increase overall
for special e.g. those >75 yrs concern – follow local policy nutritional intake
• Repeat screening: • Monitor and review care plan:
Hospital, monthly; Hospital, weekly;
Care home, at least monthly Care home, monthly;
Community, at least every 2–3 months Community, monthly

All risk categories Obesity


• Treat underlying condition and provide help and advice on • Record presence of obesity. For those with underlying
food choices, eating and drinking when necessary conditions, these are generally controlled before the
• Record malnutrition risk category treatment of obesity
• Record need for special diets and follow local policy

Re-assess subjects identified at risk as they move through care settings. A BMI of <20 kg/m2 (i.e. above the WHO BMI <18.5 kg/m2
cut-off for undernutrition) is used in the MUST score when screening patients who are unwell, to capture those whose weight is lower
than average (BMI 18.5–20) together with other criteria of undernutrition. In this setting it is more important to identify all patients
who are undernourished (high sensitivity) and less important to exclude false-positives from a dietetic assessment.

Figure 3

address nutritional risk. Additional measures may include broader malnourished patients are at risk of re-feeding syndrome, and
menu choices or providing assistance with feeding. Where these death. This risk is reduced if electrolytes are monitored closely,
‘social’ interventions are insufficient to ensure that nutritional and extra phosphate, potassium and magnesium are provided.
requirements are met, patients will need the addition of oral nutri- Nutritional replenishment will be successful in restoring body
tional supplements or enteral tube feeding, under dietetic supervi- composition and functional capacity sustainably, only if the
sion. Parenteral nutrition is rarely necessary, except in the context of underlying cause can be removed or controlled. A persisting
an inaccessible or non-functioning gastrointestinal tract. inflammatory state (high WBC, CRP, TNF) is a major obstacle to
Management of severe malnutrition includes initial resusci- synthesis and re-growth of lean tissue, so surplus energy is stored
tation, to restore hydration, and replace electrolytes. Before as fat, with little functional gain. Excess energy supply leads
feeding starts, thiamine must be provided, to avoid Wernicke’s rapidly to ectopic fat deposition especially in the liver, with
encephalopathy when carbohydrate is consumed or fed (espe- potentially fatal results. Attempts to increase appetite pharma-
cially if there is a history of alcohol excess). Severely cologically are seldom effective.

MEDICINE 39:1 49 Ó 2010 Elsevier Ltd. All rights reserved.


UNDERNUTRITION AND CLINICAL NUTRITION

Malnutrition, clinical outcome and the health economics 4 Russell C, Elia M. Nutrition screening survey in the UK in 2008.
Worcester: BAPEN, 2009.
The consequences of malnutrition for physiological function
5 Finch S, Doyle W, Lowe C, et al. National diet and nutrition survey.
have an important impact on clinical outcome. Malnourished
London: Stationary Office, 1998.
surgical patients have complication and mortality rates three to
6 Langhans W. Anorexia of infection: current prospects. Nutrition 2000;
four times higher than normally nourished patients, with longer
16: 996e1005.
hospital admissions, and incur up to 50% greater costs. Similar
7 Age Concern. Hungry to be heard. The scandal of malnourished older
findings have also been described in medical patients, particu-
people in hospital. 2006.
larly the elderly.15,16 It is often difficult to separate the delete-
8 Elia M. Changing concepts of nutrient requirements in disease: impli-
rious effects of malnutrition from the underlying disease process
cations for artificial nutrition support. Lancet 1995; 345: 1279e84.
itself, especially because each can be a cause and consequence of
9 Jeejeebhoy KN. Bulk or bounce - the object of nutritional support.
the other. However, there is clear evidence that nutrition support
J Parenter Enteral Nutr 1988; 12: 539e49.
significantly improves outcomes in these patients and it is vital
10 Haydock DA, Hill GL. Impaired wound healing in surgical patients with
that malnutrition is identified through screening.
varying degrees of malnutrition. J Parenter Enteral Nutr 1986; 10: 550e4.
Malnutrition is also a major resource issue for public expen-
11 Jackson AA. Severe malnutrition. In: Warrell DA, Cox TM, Firth JD,
diture. The British Association of Parenteral and Enteral Nutri-
Benz EJ, eds. Oxford textbook of medicine. 4th edn., vol. 1. Oxford:
tion (BAPEN) have recently calculated that the costs associated
Oxford University Press, 2003: 1054e61.
with disease-related malnutrition in 2007 in the UK were more
12 National Institute for Health and Clinical Excellence. Nutrition support
than £13 billion (greater than those associated with obesity). The
in adults. London: NICE, 2006.
potential cost savings associated with the prevention and treat-
13 Royal College of Psychiatrists and Royal College of Physicians. MARSIPAN:
ment of malnutrition are considerable e a saving as small as 1%
Management of really sick patients with anorexia nervosa. London, 2010.
represents £130 million per year. In specific situations, treating
14 Elia M, ed. The ‘MUST’ report. Nutritional screening for adults:
malnutrition produces cost savings of 10e20% or more.17
a multidisciplinary responsibility. Development and use of the
‘Malnutrition Universal Screening Tool’ (MUST) for adults. A report by
Nutritional education
the Malnutrition Advisory Group of the British Association for
The importance of training medical students and junior doctors in Parenteral and Enteral Nutrition, 2003.
nutrition has been widely recognized; a report from a working 15 Stratton R, Green C, Elia M. Disease-related malnutrition: an evidence-
party of the Royal College of Physicians stated “Every doctor based approach to treatment. Oxford: CABI Publishing, 2003.
should recognize that proper nutritional care is fundamental to 16 Stratton RJ, King CL, Stroud MA, Jackson AA, Elia M. Malnutrition
good clinical practice”.2 By addressing deficiencies in education of Universal Screening Tool predicts mortality and length of hospital
all healthcare professionals and exerting influence through clinical stay in acutely ill elderly. Br J Nutr 2006; 95: 325e30.
leadership there can be genuine improvements in nutritional care. 17 Elia M, Russell CA. Combating malnutrition: recommendations for action.
Learning objectives for Human Nutrition within Medical Report from the advisory group on malnutrition. London: BAPEN, 2009.
Training have been published on-line by the Intercollegiate 18 ICGN/Academy of Royal Medical Colleges. Objectives for nutrition in
Group on Nutrition, through its position within the Academy of medical training. Available at: www.icgnutrition.org.uk/forum/
Royal Medical Colleges.18 messages/725/icgnut_ugcurricuc_final_110908-724.doc.

Conclusions
Practice points
Malnutrition has wide-ranging effects on physiological function
applicable to all disciplines of medicine, yet is often overlooked
C Malnutrition is a common, under-recognized and under-treated
by clinicians. It is associated with increased complications
condition in hospital patients.
resulting in increased morbidity and mortality in hospital in-
C Disease-related malnutrition arises from reduced dietary
patients and significantly increased healthcare costs. Identifica-
intake, malabsorption, increased nutrient losses or altered
tion of at-risk patients through better assessment and the use of
metabolic demands.
screening tools and efficient full assessment to make the diag-
C Wide-ranging changes in physiological function occur in
nosis allows appropriate treatment to be instituted, which can
malnourished patients, leading to increased rates of morbidity
significantly improve clinical outcomes. A
and mortality.
C Re-feeding syndrome is a serious and potentially fatal
complication, which is avoidable by careful consideration of
REFERENCES nutritional treatment.
1 Elia M, ed. Guidelines for detection and management of malnutrition. C Routine nutritional screening should be undertaken in all
Maidenhead: Malnutrition Advisory Group, Standing Committee of patients admitted to hospital using a validated tool such as
BAPEN, 2000. the Malnutrition Universal Screening Tool (MUST).
2 Royal College of Physicians. Nutrition and patients: a doctor’s C Healthcare costs are significantly increased in malnourished
responsibility. A report of a working party of the Royal College of patients.
Physicians. London: RCP, 2002. C The diagnosis of malnutrition is vital for medical, social and
3 Severe malnutrition: report of a consultation to review current liter- medico-legal reasons.
ature. Geneva, Switzland: World Health Organization, 2004.

MEDICINE 39:1 50 Ó 2010 Elsevier Ltd. All rights reserved.