A Closer Look at Malnutrition in Hospitals
By Bhargavi Vatte | Kaiser Permanente San Jose Medical Center, San Jose, California, United States
I. Purpose
To discuss the concept of malnutrition from general and hospital-based aspects and to compare the cases of malnutrition at San Jose’s Kaiser Permanente to the general trends of malnutrition in hospitals.
II. What is malnutrition?
The concept of malnutrition is often associated with starvation, weakness, and poverty. However, while malnourishment may relate to being underweight, it covers a larger range of concerns.
The literal breakdown of the word “malnutrition” means bad nutrition. Individuals who are malnourished fit into three categories- undernourished, overnourished, and micro-nutrient deficient (2).
Despite the fact that the concept of malnutrition may seem simple, there is no concrete definition for the condition. There are over 15 definitions of malnutrition, each varying based on different aspects such as lack of trace nutrients, malabsorption, lack of protein, energy expenditure, etc (6). Because there is no set definition for the condition, comparing cases of malnutrition at different scales becomes difficult. This leads to problems for patients and physicians as well due to possibilities of “misdiagnosis, inappropriate or lack of nutrition intervention, and risk of payor denials” (12). Furthermore, different definitions lead to different screening and assessment methods for malnutrition in a hospital setting. Thus, due to the lack of a “gold standard” for malnutrition practices in hospitals, the various different practices appeal to different demographic groups, hindering the process of making a national benchmark screening test and assessment for this condition (18).
Different Definitions of Malnutrition
American Society for Parenteral and Enteral Nutrition’s (ASPEN) definition for malnutrition is a “combination of varying degrees of overnutrition or undernutrition with or without inflammatory activity that leads to a change in body composition and diminished function” (21).
European Society for Clinical Nutrition and Metabolism’s (ESPEN) definition of malnutrition is “a state resulting from lack of intake or uptake of nutrition that leads to altered body composition (decreased fat free mass) and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease” (18).
*Both these definitions relate to malnutrition from a clinical perspective in regards to undernutrition.
III. Protein Calorie Malnutrition
A large subcategory of the diagnosis for malnutrition is Protein Calorie Malnutrition, also known as PCM. PCM refers to a category of malnutrition in which there are inadequate amounts of protein and/or calories ingested. Parallel with the definition Kaiser Permanente uses, malnutrition, specifically PCM, is an inadequacy of nutrients to maintain a person’s health that is caused by one or more of the following factors: insufficient take, impaired absorption, increased nutrient requirements, and altered nutrients transport and utilization. This can lead to a reduction of energy for an individual affecting their everyday health and abilities. There are three “clinical syndromes” for PCM: stunting, acute malnutrition, and wasting (8). Stunting relates to a prolonged lack of micronutrients and macronutrients in infants and adolescents (8). On the other hand, acute malnutrition refers to cases of malnutrition in adults and includes kwashiorkor, marasmus, and marasmic kwashiorkor (8). Similarly, wasting occurs in adults after both acute and chronic illnesses (8).
At Kaiser Permanente, patients are coded for PCM, as malnutrition usually refers to underweight cases in a hospital setting.
IV. Prevalence of Malnutrition in Hospitals
Given the current age demographic of America, there are several elderly patients being admitted to hospitals on a daily basis. In fact, 58.3% of patients, 65 years or older, are diagnosed with malnutrition nationally (4). Patients may develop malnutrition during their hospital stays due to inadequate food intake practices; ⅓ of patients develop malnutrition during their stays (2). For example, patients who are preoperative or postoperative for a surgery will be put on NPO or tube feeding diets, requiring them to fast and change their nutritional practices. Patients may also develop “hospital acquired malnutrition” due to their dislike of hospital food or lack of hunger. Patients who are chronically diseased will gradually decrease their energy expenditure, leading to PCM, displayed through the fact that 49% of malnourished patients decrease their nutritional state during their stay (2).
However, many patients, particularly the geriatric, are admitted to the hospital, already in a malnourished state. Around 20-50% of patients are malnourished prior to their hospital admission (2). Relating back to the elderly population, “5-10% of community-dwelling older adults, 50% of those in rehabilitation, 20% in residential care and 40% in the hospital are malnourished” (3). There is a large correlation between occurrences of malnutrition and patient age in hospitals. As the American population has grown older, the effect on hospital malnutrition cases has become apparent- cases of malnutrition have tripled since 1993 (4).
Many coding cases of PCM also relate to certain patient diagnoses. It has been found that patients with malignant diseases such as chronic heart failure and inflammatory bowel diseases have had higher cases of PCM (15). Additionally, patients with cancer, tuberculosis, inflammatory bowel disease, chronic kidney disease, chronic liver diseases, cirrhosis and HIV/AIDS are more subject to PCM (8). Systemic inflammation and oxidative stress from these illnesses, such as cirrhosis and tuberculosis, contribute to malnutrition (8). These diseases can lead to “reduced dietary intake, malabsorption, altered metabolic demands, and increased nutrient losses” for patients, making them more susceptible to developing PCM. For the elderly, the occurrence of malnutrition increases by twice the amount (17).
From a more general patient standpoint, patients may experience food intake decrease due to nausea, depression, anorexia, poor dentition, and oral-motor weakness (8). This can lead to a reduced intake of micro and macronutrients, leading to PCM for the patient. Many patients are also administered several drugs to aid in their treatment plan. The polypharmacy has an effect on their taste buds, causing them to have an altered taste. In turn, this reduces their appetite and contributes to the development of PCM.
Overall, malnutrition, particularly PCM, can best be described as a “cause and consequence” of disease for patients (17).
V. Aspen’s 2020 Malnutrition Data Connection
Taking a look at ASPEN’s 2020 data for malnutrition, similar patterns can be observed. Malnourished patients have a higher rate of readmission, comorbidities, and in-hospital deaths. Additionally, these patients have higher hospital and post-discharge financial burdens. In fact, malnourished patients have a “1.4 times higher risk” for 30-day readmission than non-malnourished patients. Additionally, according to ASPEN’s data, they have a “1.9 times longer hospital stay” and a “3.4 times higher risk of in-hospital deaths” than non-malnourished patients. These shocking facts from the 2018 HCUP data show the detrimental effects of PCM in patients.
VI. Determinants for Malnutrition
There are several determinants for malnutrition ranging from various demographic and physical factors. These include (3):
Old age
Status of unmarried, separated, or divorced
Difficulties walking 100 meters
Difficulties climbing flight of stairs
Hospitalization record in the year prior to baseline
Hospitalization during the follow up period/cases of readmission
Being a male *
*Some studies have said females are more prone to malnutrition, however, a greater number of studies argue that males are diagnosed with more cases of malnutrition.
Functionality Capacity Issues with Old Age
As mentioned before, age is a large determinant for malnutrition. With older age comes limitations and effects on the physical abilities of the body.
Oftentimes, elderly citizens live by themselves at home. Due to their “lack of functionality”, they are not able to make the most nourishing food for themselves, and resort to eating processed food which enhances the risk of malnutrition (14). Moreover, their “physical and cognitive limitations” such as memory loss, weakness, and limited mobility affect their ability to consume adequate amounts of food, leading to cases of malnutrition (14). This carries over during their hospital admissions. Elderly patients, who have a hindered mobility, are not properly able to consume their hospital food. A decrease in prescribed diet consumption has a direct correlation to higher in-hospital mortality (2).
“This reality reinforces the need to invest in assessment and care protocols, especially when dealing with hospitalized patients, where factors such as poor appetite, fatigue, pain and early satiety can reduce oral food intake. Correct intervention helps reduce mortality, improve quality of life, and reduce hospitalization costs” (14).
This excerpt from “Nutritional Status and Functional Capacity of Hospitalized Elderly” highlights the importance of understanding the background for malnutrition in elderly patients, as it displays another aspect for the reasoning behind PCM in geriatric patients. Because of their hindered physical characteristics, their at-home life leads them to develop habits which facilitate PCM, putting them at risk for PCM at their house and in hospital settings. Educating patients, specifically the elderly ones, will help promote good nutritional practices in an outside of hospital setting, reducing the cases of PCM and improving their overall quality of health.
The following sequence of events in the chart displays the reality for many elderly hospital patients and their reason for a PCM diagnosis.
Increased vulnerability to PCM before hospitalization caused by decreased FC & ADL
↓
Higher PCM risk/disease effects during hospitalization
↓
Deterioration of nutritional status and health
*FC is functional capacity, ADL is activities of daily living
VII. The Effect of Malnutrition on Patients
There are a myriad of consequences for patients who are diagnosed with malnutrition, ranging from financial to health-related issues. Here are some of the most important consequences for malnourished patients:
An increase in their length of stay at the hospital
An increase in risk and rates of comorbidity
An increase in their overall hospital expenditure
A higher hospital readmission rate
A higher mortality
A higher morbidity rate
A decrease in overall health
A higher discharge to death/home care rate
A reduced response to their medical treatment
Increased Length of Stay (LOS)
It has been proven that malnourished patients have a longer length of stay at hospitals than patients who are not malnourished. Malnourished patients have 40-70% longer LOS than regular patients (2, 15). This can be attributed to the poor health effects that follow malnutrition. In their weakened state, the treatment plan of the patient is either prolonged, advanced, or changed to accommodate for their decreasing health and nutritional status. For certain cases, patients diagnosed with malnutrition can stay in the hospital for three times the number of days non-malnourished patients stay (4).
Increased Risk & Rates of Comorbidity
Patients with comorbidity have two or more diagnosed diseases at once. With the decreased health conditions that come with PCM such as “weight loss and fluid electrolyte disorder”, patients are more susceptible to developing comorbid conditions (4). Some common comorbidities patients may undergo are septicemia, pneumonia, acute renal failure, interstitial emphysema, and aspiration pneumonitis (4). These comorbid conditions facilitate the malnourished patient’s worsening state, promoting other consequences such as increased LOS, increased cost, and higher risk of infections.
Increase in their overall Hospital Expenditure
Patients who are malnourished have a longer length of stay at hospitals, directly correlating to a longer treatment and therefore a higher hospital cost. For example, the hospital bill for a non-malnourished patient was $9,485 but the hospital bill for a malnourished patient was $26,944 (4). As confirmed by the data, cost for PCM patients is often three times the cost for non-malnourished patients (4). Upon this, many PCM patients, who are usually in the elderly population, endure a health and financial burden.
Higher Hospital Readmission Rate
Malnourished patients have deteriorated health conditions that carry on after their discharge as well. Due to this, they have higher rates of readmission to hospitals. According to AHRQ and HCUP, malnourished patients had a 50% higher 30-day all-cause readmission rate than non-malnourished patients (21). With readmission, their hospital costs increase, once more displaying the relation between all the consequences caused by malnutrition.
Higher Mortality and Morbidity Rates
Malnourished patients experience higher mortality and morbidity rates. Given their subpar nutritional and health status, they experience severe fatalities which place them at risk for mortality and morbidity. In fact, “malnourished patients are eight times more likely to experience hospital falls” which can lead to added health problems and possibly death (2). They also experience higher rates of mortality in the hospital and post discharge, due to their incurred symptoms of malnutrition (2).
Overall Health Effects
Malnourished patients experience several other health defects, which contribute to their decreasing clinical condition. These issues include a decrease in muscle function, cardio-respiratory function, gastrointestinal function, immunity, and wound healing, as well as psychosocial effects such as apathy, depression, self-neglect, and anxiety (17). All these factors contribute to higher mortality and morbidity rates.
Differences in discharges
Malnourished patients experience more non-traditional discharges than non-malnourished patients do. To start, malnourished patients are twice more likely to be discharged to home care (4). Additionally, they are five times more likely to be discharged to death (4).
Reduced Response to Medical Treatment
Overall, the consequences of malnutrition on a patient hinders their treatment and recovery plan, prolonging their return to a nourished state. Each factor ties into each other, as each one furthers the effect and extent of the other.
VIII. How to target and treat malnutrition in hospital settings?
Due to the serious effects of malnutrition for patients, it is vital that patients are diagnosed with PCM at an early stage to prevent any unnecessary damage. Hence, upon admission, patients should be screened for malnutrition or risk of malnutrition so an adequate treatment plan can be put into action from an early stage.
A.S.P.E.N proposes that patients are to be nutritionally screened during their primary evaluation, which is 24-48 hours after admission. Many hospitals and studies support this proposition as well, as it has had proven benefits for patients. By screening for undernutrition at an early stage, dietitians can assess the patient's condition before it worsens. If patients are seen to be at risk, then dietitians will perform a nutritional assessment to better observe and understand the patient’s condition, so they can provide the best nutritional intervention to aid in the patient’s recovery. The “correct intervention helps reduce mortality, improve quality of life, and reduce hospitalization costs”, easing the burden of malnutrition on the patient (14).
A dietitian is essential to the recovery of a malnourished patient; the dietitians help develop a nutritional intervention plan for at-risk patients through screening, assessments, and analysis of patient records, which “improve[s] [a patient’s] nutritional status” by 77% (2).
The sequence of events below demonstrates the importance of nutritional screening and assessment for patients.
Specific identification/management of malnutrition through screening and assessment
↓
Improved prognosis of malnutrition
↓
Better nutritional intervention for patients
↓
Reduced effects of consequences on patients such as reduced LOS and costs
IX. Malnutrition Screening Tools, Assessment Tools, and Nutritional Interventions
According to ESPEN and ASPEN, nutritional screening is “a process to identify an individual who is malnourished, or at risk of malnutrition to determine if a detailed nutritional assessment is required” (18). As mentioned before, there is no national benchmark for nutritional screening; there are several different types of screening methods in use. Here are some common screening methods used throughout hospitals nationally (18).
Patient-Generated Subjective Goal Assessment: PG-SGA (1)
Patient oriented
Four questions
Observes weight, food intake, symptoms, and activities & function
Possible area for misinterpretation due to generic questions and limited answer choices
Subjective Goal Assessment: SGA (20)
More concrete and specific than PG-SGA
Different and more concrete questions asked than those in PG-SGA
Accounts for weight, dietary intake, gastrointestinal function, functional capacity, disease/comorbidities, and physical exam
Focuses on more aspects
Malnutrition Screening Test: MST (10)
Two questions
Observes weight loss and dietary intake
Quick and easy to use
Possible area for error in screening due to limited number of questions and areas for misinterpretation which can lead to additional assessments for PCM coding
Malnutrition Screening Tool for Cancer Patients: MSTC (9)
Similar to MST but specific to cancer patients
Observes change in food intake, weight loss, body mass index, and ECOG performance measure
MUST (11)
Applicable to all types of patients
5 Step screening tool
Observes BMI, weight loss, acute disease effect, risk of malnutrition, and management guidelines
Mini Nutritional Assessment Short-Form: MNA-SF (13)
Observes food intake issues, weight loss, mobility, existence of acute disease, neuropsychological stress, and BMI
Highly used for elderly patients
Other nutritional screening tests include Simplified Nutritional Appetite Questionnaire (SNAQ), Nutritional Risk Screening (NRS), Nutric Score, Nutritional Risk Index, and Geriatric Nutritional Risk Index.
Once a nutritional screening test is conducted, patients, if at risk, will go through a nutritional assessment. An assessment is a more thorough and detailed examination conducted by an RD. Because there is no national assessment either, there are several methods used. However, not all methods are verified, leading to only a few being prominently used. Here are some common nutritional assessments used nationally.
Nutrition-focused physical examination: NFPE (7)
Accounts for energy intake and interpretation of weight loss
Measures muscle wasting, subcutaneous fat loss, and reduced grip strength, edema/fluid accumulation
If a patient has at least two of these symptoms, they can be diagnosed with severe or moderate malnutrition.
Clinical Assessment
Thorough Examination conducted by RD
Nutritional screening and nutritional assessments are necessary for diagnosing malnutrition within patients. However, there are some other factors that can be used to make the diagnosis. They are insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation, and diminished functional status measured by hang grip strength (21). Malnourished patients will have one of these phenotypic characteristics and another etiologic characteristic. Once these factors, the screening tests, and the assessments are taken into consideration, the RD can code the patients for having PCM and will begin to implement the nutritional intervention plan.
Proper steps for ideal nutritional intervention for malnourished patients can be demonstrated through the Global Malnutrition Composite Score, a method used for specifically 65+ year old patients.
Global Malnutrition Composite Score (21)
Completion of screening for all hospital patients
Further assessment of patients at risk for malnutrition
Appropriate documentation of malnutrition diagnosis
Implementation of a nutrition care plan
If a patient fails to receive proper nutritional aid, their malnourishment will worsen, directly affecting their clinical conditions, clinical performance, and recovery. Thus, the role of a dietitian and the use of screening and assessment tools must be used as a part of the patient treatment plan to restore the patients health in the most efficient way possible.
X. Diagnosis Methods Used at San Jose’s Kaiser Permanente
San Jose’s Kaiser Permanente has a very efficient system for diagnosing and coding patients for PCM. The team of dietitians work alongside the doctors to formulate the best plan for the patients.
First, every patient admitted into the hospital will be screened for nutritional risk through MST. The Malnutrition Screening Test is recommended by The Academy of Nutrition and Dietetics; the Academy “indicates that MST is the tool that should be used in any patient, regardless of age, clinical history, or place where it is performed” (18). It consists of two questions with different scores depending on the answer. The highest score possible is a 7.The scores per question will be added up at the end; if the patient receives a score of two or higher, they are at risk for malnutrition. The questions, answer choices, and point values are as follows:
Have you recently lost weight without trying?
No: 0
Unsure: 2
If yes, how much weight have you lost?
2-13 lb: 1
14-23 lb: 2
24-33 lb: 3
34 lb or more: 4
Unsure: 2
Have you been eating poorly because of a decreased appetite?
No: 0
Yes: 1
The nurses will screen the patients using the MST form. From here, the dietitians will observe the MST data for the patient but will also perform a complete analysis of the patient’s medical records. By doing so, the dietitians eliminate any error that may have occurred in the screening process. From here, the dietitians know which patients are at risk for PCM and begin the assessment process.
During the assessment process, the dietitians directly interact with the patients to get the best understanding of their condition. They will first begin by conversing with the patient in regards to their nutritional and medical chart history, and will ask the patient any questions they might have. After, the dietitian will then conduct the NFPE for the patient to solidify the diagnosis for PCM. If the assessment confirms the PCM diagnosis, the dietitian will begin to create a nutritional intervention plan. Depending on the extent of the malnutrition, the dietitian may implement oral nutrition supplements, such as boost, or they may recommend tube feeding, PN, or EN support. At San Jose’s Kaiser Permanente, many patients receive aid through supplements such as boost or regimens such as TPN. The dietitians work with the doctors and the pharmacists in implementing the nutritional intervention for the patients. Together, they formulate the best plan of action for the patient to help them overcome their malnutrition and clinical condition.
XI. Diagnosis Methods Used at San Jose’s Kaiser Permanente
Protein Calorie Malnutrition is a very prevalent yet underdiagnosed condition that many patients across the globe face. There are many factors that contribute to the development of PCM such as old age, a lack of functional capacity, a lack of appetite or food consumption, etc. With the elderly demographic of America, PCM cases have exponentially increased in recent years. In terms of PCM in hospitals, there have been several advancements made towards screening and intervention methods; the most common methods include MST, MUST, and SGA. These screening methods upon admission for patients are vital to prevent them from experiencing the severe consequences. By testing for malnutrition early, patients can be put on an intervention plan earlier, helping shorten their length of stay, decrease their hospital cost, reducing their readmission rate, and improving their overall health. Malnutrition leads to poor health as it makes patients more susceptible to comorbidities, weight loss, worsening of current condition, and death.
If hospitals around the world adopted proper malnutrition screening tools, many patients' lives could be saved, aside from the fact that many patients, especially the geriatric, will improve their health and live longer lives. This goes to show the importance of the role of the dietician in the patients treatment process. Dietitians code patients for PCM and then build an intervention plan for them. They closely monitor the patient's condition, working alongside the doctors and nurses to properly assess the patient's condition.
By emphasizing education of PCM prevention and identification not only for hospital patients but for the entire population, awareness about the determinants of PCM will be better understood, helping minimize cases of malnutrition. Additionally, hospital staff members can have a more unified method of delivering the testing and screening system, eradicating any false coding cases of PCM. Because of the lack of a universal malnutrition identification method, it is difficult to compare the similarity and effectiveness of the various methods used. The lack of a universal definition for malnutrition also plays a role in the different methods for screening and testing for malnutrition. In terms of areas for improvement for PCM in hospital settings, a concrete definition and testing method across the globe would help make advancements in the treatment of PCM as well as eliminate misunderstandings and miscommunications throughout the healthcare system.
Malnutrition, contrary to popular belief, is a serious condition that exceeds the basic conception of undernutrition. Proper understanding and treatment of PCM is critical to improving a patient’s health and quality of life, helping save lives globally.
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The scientific published, “A Closer Look at Malnutrition in Hospitals,” was received on June 10, 2024, and was reviewed and accepted on June 22, 2024. To contact editors and reviewers please click here.
