BMJ  2008;336:290 (9 February), doi:10.1136/bmj.39449.723090.80

Editorials

Malnutrition in hospitals

Still common because screening tools are underused and poorly enforced

Malnutrition is a common cause and consequence of illness, particularly in older people. The number of malnourished people leaving NHS hospitals in England has risen by 85% over the past 10 years. It is still rising and reached almost 140 000 in 2006-7.¹ Surveys elsewhere consistently find that about 20% of patients in general hospitals are malnourished (body mass index <18.5 (the World Health Organization 1995 cut off for malnutrition), or thin and losing weight, or both). Figures are higher if specific nutrient deficiencies or functional indications of malnutrition are included.

Despite the frequency of malnutrition, it is undiagnosed in up to 70% of patients. This is partly because of the lack of simple laboratory tests, and because biochemical tests for nutritional status are difficult to interpret, particularly as they are often influenced by acute phase responses to inflammation in sick patients. Around 70-80% of malnourished patients currently enter and leave hospital without action being taken to treat their malnutrition and without the diagnosis appearing on their discharge summary.^{2 3}

Malnutrition affects the function and recovery of every organ system, increases the risk of infection, extends hospital stay, and makes readmission more likely. Clinicians need to be able to identify patients who have malnutrition or are at risk of malnutrition and then to refer them to dietitians or multidisciplinary nutrition support teams as appropriate, as this can greatly improve outcomes.

So how can this be achieved? In 2003, the British Association for Parenteral and Enteral Nutrition developed the "malnutrition universal screening tool"—a simple score chart that allows health professionals to identify and refer adults at risk of malnutrition. It has a high sensitivity and specificity.⁴ Other similar scoring systems exist, but they need to be validated before use in community and hospital settings.⁵

We still await an enforceable requirement to administer a validated screening tool, but nutritional scoring is now required to achieve clinical standards for patients in hospital.^{6 7} The National Institute for Health and Clinical Excellence recommended in 2006 that all patients in hospital should be screened and monitored regularly for malnutrition.⁸ However, these standards are weakly policed and are probably insufficient to stop many elderly people becoming malnourished if the quality of food is poor and there is a lack of staff to feed people.⁹

Nutritional support is an important part of medical treatment and—in relation to withholding or failing to offer it—is treated in law as equal to drugs.¹⁰ Nevertheless, hospital food is still provided by caterers who lack validated training in nutrition. Most hospitals have no designated medical posts to oversee the complex scientific matters that underpin both artificial feeding and "normal" food provision. Malnutrition is also often overlooked in residential care homes from which many patients come, even though the Care Commission for Scotland recommends that a malnutrition universal screening tool should be included in the registration process when patients are first admitted to a residential home.¹¹

The final solution to malnutrition in hospitals probably lies in recognising human nutrition as a discrete discipline, in which all medical graduates should reach a minimum level of competence, and some will specialise. The General Medical Council recognises the need for a basic understanding of human nutrition. Its publication Tomorrow’s Doctor states, "They must know about and understand the role that lifestyle, including diet and nutrition, can play in promoting health and preventing disease."¹² This is now the responsibility of deans and curriculum committees. In 1999, supported by the Department of Health and Rank Prize Funds, the intercollegiate group on nutrition—now a formal subgroup of the Academy of Medical Royal Colleges—established the intercollegiate course on human nutrition. It runs two or three times a year to provide a multidisciplinary integrated understanding of the principles of human nutrition as a minimal experience to promote safety and competence to practise. Its learning objectives and content are currently under review in relation to the changing demands of training during the foundation years. Attending the course is a necessity for the diploma in nutrition of the Royal College of Paediatrics and Child Health, and an informal requirement for higher training in gastroenterology and metabolic medicine. A strong case can be made for this course being an approvable option within training for other medical specialties, such as cardiology, diabetes, and public health.

¹ Division of Developmental Medicine, Faculty of Medicine, University of Glasgow, Royal Infirmary, Glasgow G31 2ER, ² Institute of Human Nutrition, University of Southampton, Southampton SO16 6YD

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. This is London. 140 000 NHS patients leave hospital undernourished, government admits. 2008. www.thisislondon.co.uk/news/article-23430840-details/140,000%20NHS%20patients%20leave%20hospital%20undernourished,%20government%20admits/article.do.
2. Kelly IE, Tessier S, Cahill A, Morris SE, Crumley A, McLaughlin D, et al. Still hungry in hospital: identifying malnutrition in acute hospital admissions. Q J Med 2000;93:93-8.[ISI]
3. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. BMJ 1994;308:945-8.[Abstract/Free Full Text]
4. Malnutrition Advisory Group. The "MUST" report: nutritional screening for adults. A multidisciplinary responsibility. Redditch, Worcestershire: MAG, 2003.
5. Gerasimidis K, Drongitis P, Murray L, Young D, McKee RF. A local nutritional screening tool compared to malnutrition universal tool. Eur J Clin Nutr 2007;61:916-21.[CrossRef][ISI][Medline]
6. National Health Service. Clinical standards for food, fluid and nutritional care in hospitals. 2003. http://195.92.246.148/nhsestates/better_hospital_food/bhf_downloads/nutrition/scotland_food_fluid.pdf.
7. Department of Health. Standards for better health. 2004. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4086665.
8. National Institute for Health and Clinical Excellence. Nutrition support in adults. Clinical guideline. 2006 16. http://guidance.nice.org.uk/CG32.
9. Age Concern. Hungry to be heard. The scandal of malnourished older people in hospital. 2006. www.ageconcern.org.uk/AgeConcern/Documents/Hungry_to_be_Heard_August_2006.pdf.
10. MacFie J. Ethical and legal considerations in the provision of nutritional support to the perioperative patient. Curr Opin Clin Nutr Metab Care 2000;3:23-9.[CrossRef][Medline]
11. Leslie WS, Lean MEJ, Woodward M, Wallace FA, Hankey CR. Unidentified under-nutrition: dietary intake and anthropometric indices in a residential care home population. J Hum Nutr Diet 2006;19:343-7.[CrossRef][ISI][Medline]
12. General Medical Council. Tomorrow’s doctors. Recommendations on undergraduate medical education. London: GMC, 2002.

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