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Overview

Malnutrition (referring to undernutrition) is a state resulting from a deficiency between the intake and need for energy, protein, and other nutrients, that leads to altered body form and diminished physical and mental function, as well as impaired clinical outcomes from disease1,2 .

In adults from developed countries, most cases of malnutrition are caused by a concomitant disease-related malnutrition (DRM)1. In the elderly, both age- and disease-related factors, and subsequent insufficient dietary intake contribute to a suboptimal nutritional status3,4.

 

Image Overview Disease Related Malnutrition

Prevalence

Malnutrition is a highly prevalent condition worldwide and represents a major medical and economic issue, even in developed countries. Although the prevalence of malnutrition varies greatly depending on the tool used for assessment and the population studied, it is estimated that malnutrition (or the risk thereof) affects at least 33 million people in Europe5,6 . Globally, 1 in 4 patients in hospitals, 1 in 3 patients in care homes, and 1 in 3 older adults living independently are malnourished or at risk of malnutrition5.

Symptoms

To tackle this critical health problem, the first step is to recognize the symptoms of malnutrition. The lack of interest in food, the inability to consume an adequate quantity and quality of nutrients, and general loss of appetite may derive from a non-volitional weight loss, reduced muscle mass, and weakness, among others7.

Doctor talking to happy smiling older lady

Diagnosis

In 2016, the Global Leadership Initiative on Malnutrition (GLIM) reached a global consensus on identifying and approving criteria for diagnosing malnutrition in clinical settings and determined that a two-step approach was required for a correct diagnosis7:

  • Step 1: Screening using validated screening tools to identify people “at risk” for malnutrition.

  • Step 2: Nutritional assessment comprising the evaluation of three phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and two etiological criteria (reduced food intake or assimilation, and inflammation or disease burden). For malnutrition diagnosis, GLIM established that one phenotypic criterion and one etiologic criterion should be present.

 

Doctor talking to patient with phone in hand

Intervention

Guidelines for the management of malnutrition recommend that nutritional care should be individualized depending on the patients’ needs, risks, benefits, preferences, and goals of nutrition support8-11. By incorporating a variety of nutritional care interventions, including variety of formulas with high nutrient density, flavors, and formats, it is possible to personalize the treatment of DRM and reach individual nutrition goals. Results from a large randomized controlled trial by Schuetz P. et al showed that individualized nutritional support, including oral nutritional supplements (ONS), in hospitalized patients at nutritional risk for malnutrition improved clinical outcomes, reduced short-and long-term mortality, had a positive effect on functional outcomes and quality of life, and are highly cost-effective9-10. If this intervention is not enough to meet nutritional demands, enteral tube feeding may be considered for patients with malnutrition who have functioning gastrointestinal tracts11.

Image Treaments and medications Disease Related Malnutrition

1. Cederholm T., et al. ESPEN Guidelines on Definitions and Terminology of Clinical Nutrition. Clin Nutr 2017;36(1):49-64.

2. BAPEN. Introduction to Malnutrition 2018. [Accessed December 2023]. Available from: https://www.bapen.org.uk/malnutrition-undernutrition/introduction-to-malnutrition?showall=1.

3. Norman K, et al. Malnutrition in Older Adults - Recent Advances and Remaining Challenges. Nutrients. 2021 Aug 12;13(8):2764.

4. Dent E., et al. Malnutrition in Older Adults. Lancet. 2023 Mar 18;401(10380):951-966

5. Medical Nutrition International Industry Association. Better Care Through Better Nutrition: Value and Effects of Medical Nutrition.; 2018.

6. Ljungqvist O., et al. Under Nutrition: A Major Health Problem in Europe. Nutr Hosp. 2009;24(3):369-70

7. Cederholm T., et al. GLIM Criteria for the Diagnosis of Malnutrition - A Consensus Report from the Global Clinical Nutrition Community. Clin Nutr. 2019 Feb;38(1):1-9

8. Volkert D., et al. ESPEN Guideline on Clinical Nutrition and Hydration in Geriatrics. Clin. Nutr. 2019; 38:10–47.

9. Dorner B., et al. Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings. J. Acad. Nutr. Diet. 2018; 118:724–735.

10. Thibault R., et al. ESPEN Guideline on Hospital Nutrition. Clin Nutr 2021; 40:5684–5709.

11. Schwartz D.B., et al. Ethical Aspects of Artificially Administered Nutrition and Hydration: An ASPEN Position Paper. Nutr Clin. Pract 2021; 36:254–267

12. Schuetz P., et al. Individualised Nutritional Support in Medical Inpatients at Nutritional Risk: A Randomised Clinical Trial. Lancet 2019;393(10188):2312-2321

13. Schuetz P., et al. Cost Savings Associated with Nutritional Support in Medical Inpatients: An Economic Model Based on Data From a Systematic Review of Randomised Trials. BMJ Open. 2021 Jul 9;11(7):e046402.

14. Bischoff S.C., et al. ESPEN Practical Guideline: Home Enteral Nutrition. Clin Nutr 2022 Feb;41(2):468-488