Hospital malnutrition - is it a problem? (Yes, But Only For The Patients.)

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Hospital Pharmacist Vol 7 No 6 p142

June 2000 CommentHospital malnutrition - is it a problem?By G. Grimble, BSc, PhD

and H. Peake, BSc, SRD

The British press has become as good as medical professionals at defining

malnutrition in British hospitals . Head-lines such as " Starved to death by

NHS " 1 may scream louder than the more moderate views of a hospital consultant

who said that in order to relieve the severe pressures on beds there may be a

tendency to limit care inappropriately2 but the sentiment is as clear. Some

hospitals are clearly identified as places which can convert well-fed patients

into a state of extreme cachexia.3 This debate is a variant of the old British

Railways sandwich myth which remains in the British psyche.

The best estimates of community malnutrition (ie, the proportion of underweight

people) lie between 4 and 10 per cent.4,5 In addition, patients with, for

example, chronic lung or metastatic disease or AIDS clearly contribute to a

significant amount of the malnutrition which can be detected on admission. A

recent large study performed at the Hammersmith hospital revealed that 31 per

cent of patients were malnourished. Clearly, disease-related malnutrition is no

respecter of the academic excellence of the hospital.6

What happens after hospital admission is not open to doubt. " Snapshot " studies

based on single-day audits of hospital patients have revealed 30-50 per cent of

patients with objective signs of malnutrition such as low weight for height,

muscle wasting (reduced upper-arm circumference) or reduced subcutaneous fat

stores (low skinfold thickness).7-9 Furthermore, the link between malnutrition

on admission and risk of it worsening during hospital stay is now established.

Long-stay patients are at most risk.In Dundee, two-thirds of patients reassessed

on discharge had lost, on average, 5 per cent of body-weight.7 This is a very

gloomy picture which suggests that being ill and entering hospital makes

patients mal- nourished. Illness predisposes to weight loss. Severe sepsis,

inflammatory disease and surgery switch on inflammatory mediators whose job is

to mobilise muscle tissue to provide amino acids for an effective acute-phase

response. Even where aggressive nutrition support is given,

these factors can result in marked weight loss and " stick-men " . Part of the

problem may be iatrogenic (and therefore avoidable) but is food the answer? From

a nutritionist's viewpoint it probably is. Simple measures such as adding milk

powder and butter to food, and offering snacks can have a great effect.10 It

only requires a nodding acquaintance with the laws of thermodynamics to realise

that weight loss is inevitable in patients taking in less energy than they

require. However, none of this answers the question as to whether feeding

patients does any good. An early Swiss study showed that a meagre daily

supplement of 20g protein and 254 calories reduced morbidity whether in hospital

or not. Length of stay, complication rates and mortality also dropped

significantly.11 Similar results have been shown in surgical patients.12 This

demonstrates that malnutrition in a subset of hospital patients can be reduced

by proper feeding as part of the therapy, but it fails to explain why

hospital malnutrition persists today. Allison has elegantly stated the obvious,

that " catering services need to be reorganized to address the problems of the

sick, so that appropriate food is not only prepared but delivered in a way which

makes it likely to be consumed. " 13 Even when this has been perfected, there is a

rump of patients whose hypermetabolism and cytokine-driven anorexia will lead to

weight loss. It is exciting that recent studies of fish-oils have demonstrated

reversal of the weight loss of pancreatic cancer.14 More subtly, Ljungqvist and

colleagues have shown that post-operative insulin resistance (a cause of weight

loss and muscle weakness) can be significantly attenuated if patients are given

a carbohydrate drink shortly before elective surgery.15 Finally, pharmacological

agents such as megestrol acetate can be used to stimulate appetite.

In the early 1990s, nutrition support attracted a low priority which led to the

formation of the British Association of Parenteral and Enteral Nutrition

(BAPEN). This umbrella organisation, which includes hospital pharmacists, has

brought together groups involved in nutrition support and has produced

guidelines on nutritional treatment of patients in hospital and the community.

The human factor should not be forgotten. Just as the catering ambiance often

defeated the desirability of the old British Railways sandwich, so simple

manoeuvres, such as plastic cutlery for hemiplegic patients, can defeat the best

dietetic strategies. There is still much to do.

Dr Grimble is reader in clinical nutrition, University of Surrey, Roehampton,

and Ms Peake is senior dietitian, Hammersmith hospitals NHS trust, London.

E-mails to george. Starved to death by NHS. Sunday

Express 1996, March 24.2. Laville S, Hall C. Elderly patients " left starving to

death in the NHS " . Daily Telegraph 1999, December 6. 3. " She only went in for a

sore knee " . Daily Telegraph 1999, December 6.4. Corbett J, Edington J. How much

malnutrition is there in the community? Community Nurse 1996;4:4.5. Cederholm T,

Hellstrom M. Nutritional status in recently hospitalised and free-living elderly

subjects. Gerontology 1992;38:105-10.6. Peake H, Evans S, Maltby A, Frost GS.

Determining the incidence of hospital malnutrition. Proc Nutr Soc 2000;59:In

press7. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition

in hospital. BMJ 1994;308: 945-8.8. Zador DA, Truswell AS. Nutritional status on

admission to a general surgical ward in a Sydney

Hospital. Aust N Z J Med 1987;17: 234-40.9. Larsson J, Unosson M, Ek AC,

Nilsson L, Thorslund S, Jurulf P. Effect of dietary supplement on nutritional

status and clinical outcomes in 501 geriatric patients - a randomised study.

Clin Nutr 1990;9:179-84.10. Gall MJ, Grimble GK, Reeve NJ, Thomas SJ. The effect

of providing fortified meals and between meal snacks on energy and protein

intake of hospital patients. Clin Nutr 1998;17:259-64.11. Delmi M, Rapin C-H,

Bengoa J-M, Delmas PD, Vasey H, Bonjour J-P et al. Dietary supplementation in

elderly patients with fractured neck of femur. Lancet 1990;335:1013-6.12. Keele

AM, Bray MJ, Emery PW, Duncan HD, Silk DBA. Two phase randomised controlled

clinical trial of postoperative oral dietary supplements in surgical patients.

Gut 1997;40:393-9.13. Allison SP. The management of malnutrition in hospital.

Proc Nutr Soc 1996;55:855-62.14. Barber MD, Ross JA, Voss AC, Tisdale MJ, Fearon

KC. The effect of an oral nutritional supplement enriched with

fish oil on weight-loss in patients with pancreatic cancer. Br J Cancer

1999;81:80-6.15. Thorell A, Nygren J, Ljungqvist O. Insulin resistance: a marker

of surgical stress. Curr Opin Clin Nutr Metab Care 1999;2:69-78.

 

 

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