When we hear the word malnutrition, our thoughts turn to starving children in the developing world. But another form of malnutrition which, if left undiagnosed and untreated, has an impact on a large number of people in Ireland whose health is already compromised by illness or disease.
This form of disease-related malnutrition affects about 140,000 people living either at home, in hospital or in a nursing home.
It principally affects older people with chronic disease but it also affects some people with cancer, Crohn’s disease, cystic fibrosis, multiple sclerosis and conditions that affect a person’s appetite or their ability to chew, swallow and digest food.
Dietitians and medical doctors are calling for action on disease-related malnutrition, not least because the annual healthcare costs are estimated at more than €1.4 billion, which is more than the estimated costs of obesity.
Figures also show that there are more than 250,000 extra “inpatient” bed days in Irish hospitals every year due to a longer stay caused by malnutrition.
“The problem is that some people can look overweight and still be malnourished. They can be losing muscle mass and muscle strength, and they can have fluid retention that masks weight loss.
"They can be quite thin and frail underneath," says Carmel O'Hanlon, a dietitian at Beaumont Hospital.
Cora Byrne, who was recently a patient in Beaumont Hospital, has a clear understanding of how her health problems are exacerbated by malnourishment.
“I suffer from anaemia, arthritis and leg ulcers. Sometimes I can’t eat because of mouth ulcers.
“My mood drops. I lose strength in my body and I get depressed.
“Then, when I come into hospital I’m given protein drinks, and blood, and within a few days I’m back on my food again, eating all my meals and snacking in between.”
According to Dr Declan Byrne, a geriatrician at St James's Hospital in Dublin, one in 10 older people is at risk of malnutrition, and one in four hospital patients has a similar risk.
Essentially, this means they can become malnourished when they are sick, due to the combined effect of reduced intake of food, the body’s attempt to deal with the illness, and prescribed medications.
“People with [disease-related] malnutrition are twice as likely to access GP care, three times more likely to require hospital admission and five times more likely to have complications or adverse events while in hospital,” says Byrne.
Illness itself puts more demands on the body, and low energy levels, lack of appetite or interest in eating compound the problem.
Not getting the appropriate combination of protein, fats and carbohydrates slows down wound healing and general recovery from surgery.
Another patient, who suffers from a rare bowel disease, says that she becomes malnourished because she loses interest in food after surgery.
“I’ve had 18 operations in 20 years and the pain is intolerable before I go in for surgery. In hospital, I feel weaker still until I start eating.
“For my condition, I need a high-protein, high-calorie diet so I have to have meat-based soups, eggs and extra dairy. The dietitians have as big a role to play in my recovery as the doctors,” she says.
“The more malnourished the person becomes, the lower their mood, which makes the problem more difficult to deal with,” says O’Hanlon.
O’Hanlon says the solution is to introduce nutritional screening in all hospitals and in GP clinics so that disease-related malnutrition can be treated alongside the other symptoms.
The Malnutrition Universal Screening Tool (Must) is the recommended approach to nutritional screening. One study carried out in Beaumont Hospital found that patients stayed three fewer days in the medical wards if nutritional screening and subsequent treatment for malnutrition was carried out.
“The major gap in nutritional screening is in the community and in hospitals. We recommend nutritional screening of hospital patients once a week and we encourage nutritional screening in GP surgeries,” says O’Hanlon, who is a member of the Irish Nutrition and Dietetics Institute.
The Health Information and Quality Authority (Hiqa) monitors nutritional screening in nursing homes and requires staff there to use the Must on residents regularly.
People with disease-related malnutrition have more specific dietary requirements than the general population.
In the hospital setting, disease-related malnutrition is dealt with first by offering fortified foods and oral nutritional supplements.
However, if the patient is too weak to eat, they are fed intravenously.
Call for action
The Irish Society for Clinical Nutrition and Metabolism, irspen.ie, is leading the call to action for improved nutritional screening and treatment of disease-related malnutrition. Both O’Hanlon and Byrne are members of the society.
“What we’d really like to see is that weighing and nutritional screening would happen routinely in the same way as people’s blood pressure and temperature are checked. Initially, we are trying to make sure that all hospital patients are nutritionally screened.
“But, given that 93 per cent of malnourished people are living in the community, that will have a knock-on effect on admission rates to hospitals,” says O’Hanlon.
Byrne says that reaching the malnourished people in the community is the most difficult challenge.
“The people who are at the highest risk of malnourishment are the ones who aren’t going to their doctors.”
Finding ways of reaching these individuals before they end up in hospital will require more public health campaigns.
Realising that malnutrition is not an inevitable consequence of old age or disease is the key first step, according to Prof John Reynolds, chairman of Irspen.
Making people aware that it can develop silently in many older people or chronically ill people if not picked up by screening and treatment is the next essential next step.