1. Burden of malnutrition

1.1 IDENTIFYING MALNUTRITION

Summary

‘Malnutrition‘ can include both over-nutrition (overweight and obesity) as well as under-nutrition, but in the context of this report ‘malnutrition’ (and disease-related malnutrition) is used to mean under-nutrition and nutritional risk.

Inadequate dietary intake increased nutritional needs, certain medical conditions, chronic illness or infection, as well as socioeconomic factors may lead to an individual moving from a good nutritional status to frank malnutrition in a matter of days, weeks, months or years. Severe malnutrition may be clinically obvious but as uncertainty exists in detecting lesser degrees of malnutrition screening for nutritional risk should be used to identify those individuals who are at risk of adverse outcome and who might benefit clinically from nutritional support.

A variety of nutritional risk screening tools have been developed to help identify adults and children who are malnourished or at risk of malnutrition and in most cases the tool prompts the healthcare worker to take action, i.e. to conduct or refer for in-depth nutritional assessment and to put in place a nutritional care plan to ensure that the patient’s nutritional needs are met. Generally, nutrition screening tools follow the basic principles of measuring weight/height and/or Body Mass Index (BMI), weight loss and growth in children over a prior period of time and recent appetite/food intake and are thus easy to implement.

Validated tools provide a reliable way for healthcare professionals to identify patients who are malnourished or at risk of malnutrition. It is important that the validity of a nutritional risk screening tool is considered when selecting a tool, along with other considerations such as the intended purpose of the tool, reliability and practical aspects of implementation. ESPEN recommends the following tools for use in specific healthcare settings: the ‘Malnutrition Universal Screening Tool’ (‘MUST’) in the hospital and community, Nutrition Risk Screening (NRS-2002) for use in hospitals and the Mini Nutritional Assessment (MNA) in community, long term care and rehabilitation for older people, Short Nutritional Assessment Questionnaire (SNAQ) for adults, Malnutrition Screening Tool (MST) for hospitalised adults and the Global Leadership Initiative on Malnutrition (GLIM) for adults in clinical settings. In some countries national approaches have been adopted, for example in the UK ‘MUST’ is often used in hospital and community settings to aid continuity of care. In practice the selection of a screening tool may vary from guidelines due to practical issues or local preferences. A number of tools have been developed for use in children, such as the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) that is a validated nutrition screening tool for use in hospitalised children. More work is underway to validate and assess the most suitable tools for different settings.

The different measurement approaches and populations screened explain at least in part large differences in reported values for prevalence of malnutrition and risk of malnutrition. Nevertheless, all evaluations of prevalence point in the same direction and highlight the enormous dimension of the issue.

Malnutrition is more than just weight loss. Loss of muscle mass and abnormalities or deficiencies of specific micronutrients (vitamins, minerals and trace elements) are frequently associated with malnutrition. However, micronutrient deficiencies will not be identified when screening for nutritional risk but should be taken into consideration during nutritional assessment and when planning nutritional care.

Despite the availability of screening tools, malnutrition still often goes undetected and thus untreated in hospitals, care homes and in people living in their own homes all across Europe, and other parts of the world. Often less than 50% of patients identified as malnourished receive nutritional intervention. This may be due to a lack in nutrition care systems, influenced by barriers such as cultural differences, insufficient awareness and research, the need for specialized training, and challenges in enhancing communication between care settings.

Conclusion

Although a variety of practical, validated screening tools are available for the identification of malnutrition and risk of malnutrition in children, adults and older people they are not universally employed across healthcare systems. This means that malnutrition continues to go undetected in patients in hospital, in care homes and in patients living independently. The opportunity for early identification and appropriate management of malnutrition or risk of malnutrition is therefore often missed.

Recommendations

The MNI is committed to supporting efforts to raise awareness of malnutrition and to fight malnutrition.

On the issue of identification of malnutrition the MNI makes the following recommendations:

Recommendation	Issues to Consider
National nutrition policy should be in place that addresses undernutrition as well as obesity and overweight	Nutrition policy should cover all age groups across all healthcare settings and provide a framework for a consistent approach to standards and quality improvement in nutritional care
Routine screening for vulnerable groups should be built into national nutrition policies and quality standards with audit and quality control measures included	Vulnerable groups include patients admitted to hospitals, care homes, and under the care of community/general practitioners A programme of regular audit and quality control should be implemented to ensure that screening is undertaken
Validated screening tools should be used to identify patients with malnutrition or risk of malnutrition	Selection of appropriate screening tools should take account of factors including the patient group, the setting, practical implementation and validity of the tool Guidance from professional societies and national authorities should be taken into account when selecting a suitable tool. In addition the possibility that the use of one tool across healthcare settings may facilitate continuity of care and comparisons across patient groups and care settings should also be considered
Appropriate equipment (weighing scales, stadiometers) should be made available to enable screening to take place	The equipment used for screening should comply with relevant national guidance Equipment should be regularly calibrated in line with national guidance
Agreement should be made about who is responsible for performing screening for malnutrition or risk of malnutrition	A healthcare worker with the right knowledge and skills is well placed to undertake screening, but agreement is needed on exact roles and responsibilities. Healthcare workers need to know what is expected of them Training is a critical component of ensuring that healthcare workers have the knowledge and skills to undertake screening, and when and how to act upon the results of screening Appropriate documentation of the results of screening and action planned and taken is critical for continuity of care and for audit and quality control activities

Next section →1.1.1 What is malnutrition and how is it measured?