Malnutrition and its
Consequences
Objectives
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To describe the kinds and prevalence of malnutrition
To explain the consequences of malnutrition
To describe the effect of nutrition therapy on malnutrition
To describe the advantages provided by nutrition
therapy to patient clinical condition
Types of Malnutrition
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Marasmus (Chronic)
Kwashiorkor (Acute)
Mixed
Because this is a disease with multiple etiologies, the
best terminology would probably be polydeficient
malnutrition.
Green CJ. Clin Nutr 1999;18(s):3-28
Hospital Malnutrition:
Critical Evidence
The Skeleton in the Hospital Closet
• Height not recorded in 56% of cases
• Body weight not recorded in 23% of cases
• 61% of those whose weight was recorded lost > 6 kg
• 37% had albumin < 3.0 g/dL
“I am convinced that iatrogenic malnutrition has become a significant
factor in determining disease outcomes in many patients.”
Butterworth CE. Nutr Today 1974
Hospital Malnutrition:
Prevalence
• Numerous studies on hospital malnutrition have been
published.
• Prevalence of malnutrition in U.S. hospitals today
ranges from 30% to 50%.
• Patient’s nutritional status declines with extended
hospital stay.
Coats KG et al. J Am Diet Assoc 1993
Malnutrition Among Hospitalized Patients:
A Problem of Physician Awareness
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Up to 50% of hospitalized patients may be
malnourished on admission
Before nutritional assessment training:
– Only 12.5% of malnourished patients are
identified
After 4 hours of training:
– 100% of patients are identified
Roubenoff et al. Arch Intern Med 1987
Prevalence of Malnutrition in
Hospitalized Patients
10%
Severely Malnourished
69%
Adequate
Nutritional
State
21%
Moderately
Malnourished
Detsky et al. JPEN 1987
Prevalence of Malnutrition in
Hospitalized Patients
In a published British study:
• 46% of general medicine patients
• 45% of patients with respiratory problems
• 27% of surgical patients
• 43% of elderly patients
Percentage of malnourished patients at time of
admission
McWhirter et al. Br Med J 1994
Hospital Malnutrition in Brazil
Study of 4,000 patients in 25 hospitals to evaluate the
prevalence of hospital malnutrition and awareness by
health care providers.
Findings:
• 12.6% severe malnutrition
• 35.5% moderate malnutrition
• Prolonged length of stay directly linked to malnutrition
• Little awareness about the importance of nutritional status of
hospitalized patients
Waitzberg et al. Nutrition 2001
Prevalence of Malnutrition –
(in your country)
Enter hospital
malnutrition data for your
country
Reference:
Malnutrition and its Consequences
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Changes in intestinal barrier
Reduction in glomerular filtration
Alterations in cardiac function
Altered drug pharmacokinetics
Roediger 1994; Green 1999; Zarowitz 1990
Malnutrition and its Consequences
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Loss of weight
Slow wound healing
Impaired immunity
Increase in length of hospital stays
Increased treatment costs
Increase in mortality
Malnutrition and Increased
Complications
Many studies have shown that complications
are 2 to 20 times more frequent in
malnourished patients than in well-nourished
patients.
Buzby et al. Am J Surg 1980
Hickman et al. JPEN 1980
Klidjian et al. JPEN 1982
Malnutrition and
Slow Wound Healing
Foot Amputation
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86% of well-nourished patients healed without
problems
Only 20% of malnourished patients healed
successfully
Dickhaut SC et al. J Bone Joint Surg Am 1984
Malnutrition and Increased
Complications
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42% of severely malnourished patients suffer major
complications
9% of moderately malnourished patients suffer
major complications
Severely malnourished patients are four times more
likely to suffer postoperative complications than
well-nourished patients
Detsky et al. JAMA 1994
Malnutrition and Increased
Complications
Patients “at risk for malnutrition” were
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2.6 times more likely to suffer complications.
3.4 times more likely to suffer major complications
than persons not at risk for malnutrition.
Reilly J et al. JPEN 1988
Cumulative Mortality
50
PEM
non-PEM
% Mortality
40
30
20
10
0
0
1
2
3
4
5
6
7
8
9
Months After Hospitalization
Reprinted from: American Journal of Medicine (Cederholm T, Jägrén C, Hellström K. Outcome of Protein-Energy
Malnutrition in Elderly Medical Patients, 1995;98:67-74) with permission from Excerpta Medica Inc. Copyright 1995.
Risk of Malnutrition – Hospital Costs
30,000
Risk of Malnutrition
Cost per Patient
(US dollars)
25,000
26,359
No Risk of Malnutrition
18,896
20,000
15,000
11,174
10,000
5,000
0
7,902
6,858
4,979
Pneumonia
Intestinal Surgery
Complications
Reilly J et al. JPEN 1988
Hospital Stay
Nutritional Status
Malnutrition increases time and costs
Severe
Mild
Normal
0
5
10
Days
15
20
Robinson et al. JPEN 1987
Impact of Nutrition Therapy
in Patient Outcomes
Nutrition Therapy Affects Outcomes:
Improvement in Pre-albumin with PEG
Pre-albumin
Body weight
Pre-albumin Levels
(mg/kg)
64
300
63
250
62
61
200
0
2
4
6
8
10
12
Weeks of Radiation Therapy
Fietkau et al. Recent Results Cancer Res 1991
Body Weight (kg)
65
350
Nutrition Therapy Affects Outcomes:
Fewer Complications
Number of Complications
15
1st hospitalization
2nd hospitalization
At 6 months
With Nutrition Therapy
Without Nutrition Therapy
10
5
0
n = 28 n = 32
n = 9 n = 15
n = 25 n = 27
n = Number of hip fracture patients
Delmi M et al. Lancet 1990
Nutrition Therapy Affects Outcomes:
Quality of Life Index
Quality of Life Index
(arbitrary units)
2
Without PEG
With PEG
1
*p = 0.038
0
-1
*
Radiation Therapy
-2
0
2
4
6
12
Weeks
18
24
Senft et al. Supp Care Cancer 1993
Nutrition Therapy Affects Outcomes:
Early Nutrition
Length of Stay (days)
80
40
76 Days
30 Days
0
Fed at 3 days
At 7 days
Garrel et al. J Burn Rehabil 1991
Summary
Malnutrition
• Extensive prevalence
• Linked to:
 Increased complications
 Increased length of hospital stay
 Higher costs
 Increased mortality
• As there is adequate documentation that demonstrates
outcome improvement, nutritional therapy must become
an integral part of patient care.