Malnutrition in the developed world

April 1, 2012

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The European Food Information Council, Brussels, Belgium

“The World Health Organization (WHO) defines malnutrition as “the cellular imbalance between supply of nutrients and energy and the body's demand for them to ensure growth, maintenance and specific functions” (1). Essentially, malnutrition occurs when the body does not receive enough energy or essential nutrients, such as protein, vitamins, minerals and other nutrients needed to maintain healthy tissues and organ function. The condition is not confined to people who are undernourished: overweight and obese people can suffer from it, too.

Nutrient intakes can be restricted due to illness, excessive dieting, severe injury, lengthy hospitalization or substance abuse, such as excessive alcohol or drug intake. Different disorders can develop depending on which nutrients are lacking or consumed in excess, but some general symptoms include fatigue, dizziness and unintended weight loss. Malnutrition can result in compromised immune responses, which may lead to an increased risk of infections, poor wound healing, delayed recovery from illness and longer hospitalization (2). Other consequences include impaired muscle function, poorer quality of life, increased mortality, as well as increased healthcare resource use and costs (3).

In Europe, an estimated 33 million people are at risk of malnutrition (4). Studies show that up to one-third of patients in hospital and nursing homes are at risk of undernutrition, as are 10% of individuals over the age of 65 in the European Union (3, 5). Older people living either alone at home or in nursing homes are particularly vulnerable. Among other factors, appetite tends to decrease in the latter group, leading to reduced food and nutrient intake (6). Other key risk groups are people with chronic diseases, people who live in poverty or are socially isolated, and people who have recently been discharged from a hospital (3). In addition, individuals undergoing rapid growth, such as infants, adolescents and pregnant women, have higher nutritional needs than others, which makes them more susceptible to the effects of poor nutrition. Extremely premature infants are a high risk group and may need a five or sixfold increase in their weight before they can be discharged from hospital care.

There are various screening tools available to help detect malnutrition risk. One of the most well-known screening tools, which was developed in the UK, is called the Malnutrition Universal Screening Tool (MUST) (7). MUST has been designed to help identify adults who are underweight and at risk of malnutrition, though it also takes into consideration those who are obese. However, it is not used to detect deficiencies in, or excessive intakes of, vitamins and minerals.

The general awareness surrounding the issue of malnutrition remains poor. Large scale studies in the UK and the Netherlands have shown that about 1 in 4 patients are at risk of malnutrition upon admission to hospital and many more go undiagnosed due to inadequate screening (3, 8–10). Similarly, the project “NutritionDay”, which has surveyed thousands of hospital patients across the European Union (EU), showed that less than half of patients ate all their meals while in hospital (11). Health professionals have an important role in ensuring that patients meet their nutritional requirements while in the hospital, yet the amount of knowledge and awareness of nutritional problems is low among caregivers (12). As a consequence, malnutrition remains under-recognized and under-treated despite the existence of treatment guidelines. Often, nutrition therapy has no place within health and social care budgets (13).

Across Europe, malnutrition is associated with increased morbidity, prolonged hospital stays and higher health care costs (13). This impact has been studied in numerous patient groups (5). The figures for the community are alarming, with the proportion of malnourished patients reaching 60% for certain diseases (12). In the EU, the cost of treating patients with disease-related malnutrition is considerable and approxi-mately twice that of the management of obesity and its consequences (14). It is estimated that the cost of malnutrition to the EU alone is a staggering €120 billion per year (5). In light of this, it is high time nutrition and health strategies concentrated on the important problem of malnutrition among undernourished people. Interventions to ensure appropriate nutritional care would be cost-effective, and the impact of nutritional support is well known from many clinical trials (3, 13). Although there may be strategies in place to prevent undernutrition, nutritional support is often not considered an important therapeutic tool for the management of patients.

A balanced diet that provides the necessary energy and nutrition for a healthy person may not be sufficient when there is existing chronic malnutrition. To allow recovery of nutritional status, nutritionalrequi@@rements may be increased compared with the requirements for a healthy, nourished person. It is often not feasible for people who are undernourished as a result of disease to meet their requirements via the diet alone. This challenge is partially due to the fact that many suffer from a chronic loss of appetite, which affects food intake, though other factors also impair food intake. In these cases dietary supplements can be a solution.

Public health policies across Europe need to acknowledge that malnutrition is not only a problem in the developing world, but also affects a large number of people in industrialized countries. They need to include measures to raise awareness about the importance of a varied and balanced diet for good health, and about the disease risks associated with poor nutritional intake.”

Based on: The European Food Information Council. Time to recognise malnutrition in Europe. FOOD TODAY 03/2012.

References

  1. World Health Organization; UNICEF; UN System Standing Committee on Nutrition. WHO, UNICEF, and SCN informal consultation on community-based management of severe malnutrition in children – SCN Nutrition Policy Paper No. 21. 2006.
  2. Kondrup J. et al. Incidence of nutritional risk and causes of inadequate nutritional care in hospitals. Clin Nutr. 2002 ; 21(6):461–468.
  3. Disease-Related Malnutrition: An Evidence-Based Approach To Treatment, edited by Rebecca J Stratton, Ceri J Green, and Marinos Elia, 2003, 824 pages. CABI Publishing, Wallingford, United Kingdom.
  4. Ljungqvist O. and de Man F. Undernutrition – A major health problem in Europe. Nutr Hosp. 2009 ; 24:368–370.
  5. Ljungqvist O. et al. The European fight against malnutrition. Clin Nutr. 2010 ; 29(2):149–150.
  6. Donini L. M. et al. Eating habits and appetite control in the elderly: the anorexia of aging. Int Psychogeriatr. 2003 ; 15(1):73–87.
  7. Todorovic V. et al. (eds) on behalf of the Malnutrition Advisory Group (2003). The ‘MUST’ Explanatory Booklet. A Guide to the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for Adults.
  8. Russell C. and ELia M. Nutrition Screening Survey in the UK in 2008: Hospitals, care homes and mental health units. 2009. Redditch, BAPEN.
  9. Kruizenga H. M. et al. Screening of nutritional status in The Netherlands. Clin Nutr. 2003 ; 22:147–152.
  10. Meijers J. M. et al. Malnutrition prevalence in The Netherlands: results of the annual Dutch national prevalence measurement of care problems. Br J Nutr. 2009 ; 101:417–423.
  11. Hiesmayr M. et al. Decreased food intake is a risk factor for mortality in hospitalised patients: the NutritionDay survey 2006. Clin Nutr. 2009 ; 28(5):484–491.
  12. Hajjar R. et al. Malnutrition In Aging. The Internet Journal of Geriatrics and Gerontology. 2004 ; 1(1).
  13. Stratton R. J. and Elia M. A review of reviews: A new look at the evidence for oral nutritional supplements in clinical practice. Clin Nutr Suppl. 2007 ; 2(1):5–23. 
  14. Russell C. A. The impact of malnutrition on healthcare costs and economic considerations for the use of oral nutritional supplements. Clin Nutr Suppl. 2007 ; 2(1): 25–32.