Dr. Michael Meguid was a professor of surgery on duty at Boston City Hospital in August 1976 when he was called in one night for an emergency. An 18-year-old man named LeRoy had fallen from a ledge. LeRoy had a fractured thigh bone, which an orthopedic team worked quickly to repair. When they were finished, the patient was taken to the intensive care unit. He was going to make it, Meguid remembers thinking. To his surprise, LeRoy died 30 days later.
In the hospital, under the care of the orthopedic team, LeRoy’s only nourishment came from an intravenous drip. During those 30 days, LeRoy’s calorie intake was equivalent to “about two candy bars a day,” Meguid wrote in a 2015 Columbia Medical Review article.
LeRoy received about a sixth of the total nourishment that was required for him to survive and recuperate after two major surgeries. In the absence of that nourishment, his body resorted to converting his muscles to glucose. LeRoy’s medical records did not state it, Meguid said, but in reality the cause of his death was hospital-induced malnutrition.
More than 40 years after LeRoy’s death, new research indicates that malnutrition in hospital settings remains under-diagnosed and – even when detected – undertreated. Experts say this persistent lack of awareness about the dangers of malnutrition could be contributing to as much as $42 billion in healthcare costs, 54 percent higher readmission rates, hospital stays for malnourished patients that are twice as long as expected and an unknown number of deaths.
This has spurred new efforts to educate doctors and nurses on the signs of malnutrition and to encourage them to consult dietitians about how to prevent it happening in the first place.
A Problem of Awareness
Research has shown that the prevalence of malnutrition in hospitals is between 20 to 50 percent of patients. But in an analysis of nearly 6 million adult hospitalizations, Dr. Kenneth Nepple, a urologist and professor at the University of Iowa, found that only 5 percent of patients had been given a malnutrition diagnosis. That seems to indicate that malnourished patients are falling through the cracks. The study analyzed hospitalizations at 105 academic medical institutions across the country between 2014 and 2015.
This has significant ramifications. Dr. Isabel Correia, a professor of surgery at the Federal University of Minas Gerais in Brazil, who has authored several papers on malnutrition among hospitalized patients, told News Deeply that malnourished patients had a three times higher mortality risk than other patients.
Being a urologic surgeon specializing in cancer care, Nepple has observed this first-hand. “A disease process like cancer produces a catabolic state where the cancer is using some of the nutrients that are normally used to do restorative things like wound healing,” Nepple said. If the patient is also malnourished, she may not be able to recover as well from surgery or may be at a higher risk of having post-operative complications, he said.
Children are at an even higher risk of hospital malnutrition. Unlike adults, children don’t just need calories to maintain their weight, says Jenni Carvalho, a pediatric dietitian at Texas Children’s Hospital. “They need calories to grow cognitively and physically. Therefore, it takes a lot less time for children to become malnourished,” she said.
Involving dietitians in the care of hospitalized patients would seem to go a long way both in identifying malnutrition and also treating it effectively. That is not always the case, though.
A 2017 study published in the journal “Current Developments in Nutrition” found that roughly two-thirds of the patients identified as at risk of malnutrition received a consultation with a dietitian or an order for oral nutrition supplement, but only 14 percent received a malnutrition diagnosis.
One reason for the gap between screening and intervention or diagnosis is a lack of communication between physicians and nutrition experts, Nepple said.
“For example, if a patient is identified as potentially at risk of malnutrition by a dietitian, that assessment may work its way into the medical record as a dietitian’s note,” he said. “But if no one reads that note or talks to the dietitian about the evaluation, it’s not going to have much impact.”
The solution, experts said, might rest on making the doctors and nurses more aware of malnutrition – encouraging them to look for signs and to ask pertinent questions.
The National Research Council recommends that medical schools teach nutrition for a minimum of 25 hours. According to a 2015 study published in the “Journal of Biomedical Education,” 71 percent of accredited U.S. medical schools failed to hit that target.
“Since we’re not trained, we don’t recognize its importance and we don’t demand consultation with experts,” Correia said. “It’s a vicious circle.”
There was a brief period of progress in the late 1970s and ’80s when various nutrition societies were formed and laws mandating nutrition screening were passed in the United States, but momentum eventually slowed. New efforts are gaining traction, though. They are collaborative, trying to bring together dietitians, physicians and nurses to focus on the problem.
Nepple pointed to the Malnutrition Quality Improvement Initiative, a set of guidelines for physicians, nurses and other healthcare professionals aimed at improving outcomes for malnourished or at-risk hospitalized older adults. Others include Enhanced Recovery After Surgery, a set of protocols that incorporate nutritional care after surgery. It was started for colorectal surgery, but has since spread to many different specialties. And Strong for Surgery is a pre-surgery checklist that includes checking nutritional status. It was developed by surgeons in Washington state to improve clinical outcomes.
There is also an opportunity to raise awareness among patients, Correia said, and make sure they and their families are asking questions about their own nutritional status. “That’s why I call it the hidden burden of malnutrition, because it’s there but nobody cares about it,” she said.