It Takes a Village to Fight Clinical Malnutrition

In 1974, Charles Butterworth, MD, wrote a landmark article titled “The Skeleton in the Hospital Closet,” which brough to light clinical malnutrition’s adverse effect on the treatment and recovery rates of inpatients. Fast-forward nearly four decades, and studies in the Journal of the American Medical Association, Journal of the Academy of Nutrition and Dietetics, Journal of Parenteral and Enteral Nutrition and Clinical Nutrition indicate hospital malnutrition continues to be a pervasive problem.

In the U.S., one in three patients admitted to a hospital is considered malnourished — and of those patients who aren’t clinically malnourished upon arrival, one-third is at risk of becoming so during their stay.

“There is a world of difference in the past few decades and lots of challenges to make sure patients are evaluated and treated for malnutrition in a timely manner,” says George Blackburn, MD, associate professor of surgery and nutrition at Harvard Medical School. “Diseases are more complex, people live longer with their diseases and hospitalized patients today are older, sicker and chronically ill.”

In fact, clinical malnutrition goes unrecognized in up to 55 percent of hospitalized patients. Adding to the problem, says Ainsley Malone, MS, RD, CNSC, LD, president of A.S.P.E.N. and nutrition support dietitian at Mount Carmel West Hospital in Columbus, Ohio, is that many nutrition teams have been disbanded and each department independently delivers its own — and therefore often fragmented — nutritional care.
In an era of controlled reimbursements, smaller staffs, tighter budgets and stringent Joint Commission standards, one area of care that can slip through the cracks is nutrition evaluation and support. However, studies show that prevention and treatment of clinical malnutrition improves overall quality of patient care, improves clinical outcomes and ultimately reduces costs.

For example, a recent study in the Journal of the Academy of Nutrition and Dietetics suggests that documenting calorie requirements within 48 hours in medical records can lead to more appropriate calorie intake and improved clinical outcomes. And research in the February American Journal of Managed Care found that offering oral nutrition supplements to hospitalized patients led to reductions in length of stay, costs and readmissions.

“It starts by identifying malnourished or at-risk patients upon admission for immediate intervention,” says Malone. Critical details such as body mass index, nutrition screening assessment, disease risks, admission weight and changes in weight can be documented and, through electronic health records, connected to previous records and made available to the medical team members for continuous care.

To address the issue of malnutrition both in the hospital and after discharge, a group of interdisciplinary professional organizations known as the Alliance to Advance Patient Nutrition has developed practice strategies for RDs, nurses, hospitalists, physicians and other clinicians to collaborate, diagnose and treat at-risk patients. (Visit for more information.)

Meanwhile, through the Affordable Care Act, regulations are in place to offer higher levels of reimbursement for improved care, which mean hospitals may be rewarded for early diagnosis and treatment of malnutrition — or potentially penalized if they miss the diagnosis.

“Hospitals have an incentive to provide optimal care and really can’t afford to miss malnutrition. Otherwise outcomes will be complicated, lead to readmissions and impact the bottom line,” adding that the solution will require collaboration and leadership. “Dietitians are the baton holders with the knowledge and expertise to lead the interdisciplinary team and put an end to clinical malnutrition,” says Blackburn.

For many practitioners, better health and recovery rates for their patients is incentive enough. And while clinical malnutrition may not be a new problem, between an aging population and increases in chronic disease across the board, adopting a comprehensive and collaborative approach to diagnoses and interventions may be as important as ever.

Kathleen Zelman
Kathleen Zelman, MPH, RDN, is the nutrition director of WebMD.