UNDERNUTRITION AND CLINICAL NUTRITION

Malnutrition and What’s new?

undernutrition C NICE guidance on nutrition support in adults
John Saunders
C Detailed nationwide BAPEN survey assessing nutritional status
of hospital admissions revealed the extent of the problem
Trevor Smith C The high estimated financial cost of malnutrition has focused
Mike Stroud political attention on addressing the problem of malnutrition
C Objectives for Nutrition in Undergraduate Medical Training
(ICGN/Academy of Royal Medical Colleges)

Abstract
The term malnutrition is used to describe a deficiency, excess or imbal-
ance of a wide range of nutrients, resulting in measurable adverse effects
on body composition, function and clinical outcome.1 As such it can refer
to individuals who are either over- or under-nourished although it is
frequently used synonymously with undernutrition, as is the case in
this article. Although it is well known that malnutrition is common
in the developing world, the fact that significant malnourishment occurs
in UK society and health settings is not widely appreciated. Malnutrition
occurs for psychosocial reasons and as a consequence of disease. It has
direct effects on clinical outcomes and is associated with massive health-
care expenditure. Recognition and treatment can have a significant
impact on patient care and can reduce costs. Failure to diagnose and
manage carries medico-legal risks. It is the responsibility of all doctors
to recognize the fundamental importance of proper nutritional care to
good clinical practice.2 The focus of this article is predominantly con-
cerned with malnutrition and its consequences in the UK.
Keywords clinical outcome; health economics; malnutrition; MUST
score; re-feeding syndrome; screening
In the UK, malnutrition remains an under-recognized problem
facing patients, clinicians and the wider society. It is not only very
common in hospital and institutional care settings but is widespread
in the community. It is both a consequence and a cause of disease.
Approximately 2% of the UK population are underweight e defined
as a body mass index (BMI) below 18.5 kg/m2 e but this is an
underestimate of malnutrition, since those who unintentionally lose
weight from a position of relative excess may also be at risk what-
ever their BMI. The prevalence of malnutrition in the free-living
elderly or those with chronic diseases increases at least two-fold and
individuals in institutional care have a prevalence of malnutrition
between 30 and 42%.4
UK hospital patients with malnutrition are particularly likely to be
malnourished for reasons summarized in Table 1. In a large national
survey conducted in 2008, 28% of patients admitted in hospital were
at risk as indicated by a high score on the MUST screening tool. The
prevalence was particularly high in specific sub-populations (e.g.
34% of all emergency admissions and 52% of admissions from care

Causes of malnutrition and further deterioration in

nutritional status among hospital in-patients
The term malnutrition is used to describe a deficiency, excess or
imbalance of a wide range of nutrients, resulting in measurable Medical causes of C Anorexia of disease
adverse effects on body composition, function and clinical inadequate and/or C Nausea and vomiting
outcome.1 It is the responsibility of all doctors to recognize the poor’quality oral intake C Gastrointestinal dysfunction
importance of proper nutritional care to good clinical practice.2 C Reduced absorption of macro-
Worldwide, more than 3.5 million mothers and children under 5 and/or micro-nutrients
die unnecessarily each year owing to malnutrition,3 and around C Increased nutrient loses
178 million children have stunted growth. Micronutrient defi- C ‘Nil by mouth’ for investigation
ciencies affect huge numbers; iodine deficiency alone is thought or medical reasons
to affect about 2 billion people. C Physical disability and inability
to feed self

John Saunders MRCP is a Research Fellow in Clinical Nutrition at the Environmental causes of C Inadequate food quality
Institute of Human Nutrition and a Specialist Registrar in inadequate and/or poor’ C Inadequate food availability
Gastroenterology at Southampton University Hospital, Southampton, quality oral intake C No protected meal times
UK. Competing interests: none declared.
C Inadequate training and
knowledge of medical and
Trevor Smith MRCP is a Consultant in Clinical Nutrition and Gastroenterology nursing staff
at the Institute of Human Nutrition and Southampton University Hospital, Altered requirements C In critical illness there are altered
Southampton, UK. Competing interests: none declared. substrate demands and several
sub-groups of patients have a
Mike Stroud BSc MD DSci FRCP is a Consultant Gastroenterologist and increased energy expenditure
Senior Lecturer in Medicine and Nutrition at the Institute of Human (see below)
Nutrition and Southampton University Hospital, Southampton, UK.
Competing interests: none declared. Table 1

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 UNDERNUTRITION AND CLINICAL NUTRITION

homes).4 Many patients also see a further decline in their nutritional
status during their hospital admission, which can then increase their
risk of complications and length of stay.
Micronutrient deficiencies: in the UK, specific micronutrient defi-
ciencies are also surprisingly common, especially in the elderly.
Folate deficiency has been described in 29% of independent adults
over 65 years old and 35% of those in institutions, while vitamin C
deficiency affects 40% of those in institutional care.5
Causes of malnutrition
Although a proportion of malnutrition in developed countries is
associated with poverty, social isolation and substance misuse,
exacerbating the health inequalities in vulnerable populations,
most adult malnutrition in the UK is associated with disease,
arising from several sources (Figure 1).
Reduced dietary intake is probably the single most important
aetiological factor in disease-related malnutrition. This can be the
result of many psychosocial conditions, importantly including
age, depression, and dementia. During illness there is commonly
reduction in appetite sensation owing to modified secretion of
cytokines, glucocorticoids, peptides, insulin and insulin-like
growth factors.6 In hospital in-patients, these problems may be
compounded by failure to provide regular nutritious meals, to
protect them from routine clinical activities, and to offer help and
support with feeding when required.7 Among patients under-
going abdominal surgical procedures, varying degrees of intes-
tinal failure (whether short-term or more sustained) add further
nutritional risks. While there is usually a rebound of appetite
after recovery, to restore lost weight and functional capacity, this
response is suppressed by continued inflammation, or by the
early recurrence of the precipitate illness, e.g. in patients with
chronic obstructive pulmonary disease (COPD).
Although for many years it was thought that increased energy
expenditure was predominantly responsible for disease-related
malnutrition, there is now clear evidence that in many disease states
total energy expenditure is actually less than that measured in
normal health. The basal hypermetabolism of disease is offset by
a reduction in physical activity, with studies in intensive care
patients demonstrating that energy expenditure is usually below
2000 kcal/day.8 Weight loss in patients with persistent inflammation
or neoplasia may be accompanied by altered demands for specific
amino acids in disease states. The body meets these needs by
drawing on its reserves, with excess lean tissue wasting. This may be
evident as cachexia in a thin patient, but loss of lean tissue (sac-
rcopenia) can be more difficult to detect in an overweight patient.
Consequences of malnutrition
Malnutrition affects the function and recovery of every organ
system (see Figure 2).
Muscle and bone: weight loss caused by depletion of fat and muscle
mass, including organ mass, is often the most obvious clinical sign
of malnutrition. The visible loss of lean tissue is often described as
cachexia and may be hidden in obese patients. Muscle function
declines before changes in muscle mass occur, suggesting that
altered nutrient intake has an important functional impact inde-
pendent of the effects on muscle mass; similarly, improvements in
muscle function with nutrition support occur more rapidly than can
be accounted for by replacement of muscle mass alone.9 Bone mass
is lost during weight loss and specifically when intakes of calcium,

Effects of malnutrition
Causes of malnutrition • Psychology:
• Ventilation: depression/
Altered nutrient Inadequate intake loss of muscle apathy
processing • Poor diet and hypoxic
• Increased/altered • Poor appetite responses
• Reduced cardiac
metabolic demands • Pain/nausea with output
• Liver dysfunction food
• Impaired liver
• Dysphagia
function and fatty
• Depression
change/necrosis
• Unconsciousness
• Impaired renal
function
• Impaired gut
intregrity and
Excess losses
immunity
• Vomiting
• NG tube
• Reduced
drainage • Decreased strength
• Diarrhoea immunity and
• Surgical resistance to
drains infection
• Fistulae
• Stomas
Malabsorption • Impaired • Hypothermia
• Pathology of stomach, wound healing
intestine, pancreas
and liver

Figure 1 Figure 2

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 UNDERNUTRITION AND CLINICAL NUTRITION
magnesium and/or vitamin D are insufficient. Bones are slow to re-
form during recovery, and fracture risk is high.
Cardiovascular and respiratory: a reduction in cardiac muscle mass
is recognized in malnourished individuals. The resulting decrease in
cardiac output has a corresponding impact on renal function by
reducing renal perfusion and glomerular filtration rate. Micronutrient
(e.g. thiamine) and electrolyte deficiencies may also affect cardiac
function, particularly during re-feeding. Poor diaphragmatic and
respiratory muscle function reduces cough pressure and expectora-
tion of secretions, delaying recovery from respiratory tract infections.
Gastrointestinal: adequate nutrition is important for preserving
gastrointestinal function; chronic malnutrition results in changes in
pancreatic exocrine function, intestinal blood flow, villous archi-
tecture and intestinal permeability. Loss of digestive enzymes
occurs early with dietary energy restriction and commonly leads to
secondary lactose intolerance, with diarrhoea. The colon loses its
ability to reabsorb water and electrolytes, and secretion of ions and
fluid occurs in the small and large bowel. This may result in diar-
rhoea, which is associated with a high mortality rate in severely
malnourished patients.
Immunity and tissue repair: immune function is suppressed early
with underfeeding as a result of impaired cell-mediated immunity
and cytokine, complement and phagocyte function, and this
increases the risk of infection. Delayed wound healing is also well
described in malnourished surgical patients.10 Malnourished
patients are at particular risk from respiratory tract infections, and
any bacterial or parasitic infection is liable to progress rapidly.
Fever, and usual markers of acute inflammation (WBC, CRP) may
be suppressed in malnutrition, so early antibiotics may be advised.
Endocrine: most endocrine functions are suppressed by malnu-
trition. Specifically, T4 and T3 are reduced, while reverse T3
rises. Thyroid-stimulating hormone is usually normal, unless
iodine status is impaired. Gonadotrophins are suppressed, and
testerone and oestrogen/progesterone all fall. Amenorrhoea is
usual. Insulin secretion is reduced, but insulin sensitivity rises
during undernutrition, so blood glucose remains low-normal.
Hypoglycaemia is a very late pre-terminal development but may
also indicate occult sepsis. During re-feeding, insulin resistance
may result in a form of ‘malnutrition-related diabetes’.
Psychological: in addition to these physical consequences,
malnutrition also results in psychosocial effects, such as apathy,
depression, anxiety and self-neglect.
Reductive adaptation: a down-regulation of energy-dependent
cellular membrane pumping (Na/K-ATPase) and other basic
cellular metabolic functions, is one explanation for the conse-
quences of malnutrition. In complete starvation, the process
begins very early. It is less striking when dietary intake is simply
insufficient to meet requirements and the body has time to draw on
its functional tissue reserves within muscle, adipose tissue and
bone, although this then leads to detrimental changes in body
composition. Both reductive adaptation and tissue wasting have
direct consequences on tissue function, with loss of functional
capacity and a potentially brittle metabolic state. Rapid decom-
pensation occurs with insults such as infection and trauma.11
MEDICINE 39:1
Re-feeding syndrome describes the potentially life-threatening
consequences that can occur as a result of acute micronutrient
deficiencies, fluid and electrolyte imbalance and organ dysfunc-
tion caused by administration of unbalanced or over-rapid
nutritional support in patients at risk (see Table 2). Patients
particularly at risk are those with little or no oral intake for
protracted periods and those who are severely malnourished (see
Table 3). Patients with limited nutritional intake, altered meta-
bolic demands and/or increased losses undergo reductive adap-
tation and, as a result are deficient in vitamins, trace elements
and electrolytes. There is a whole body and intracellular deple-
tion of potassium, magnesium and phosphate, and a consequen-
tial increase in intracellular sodium and water. There is also
a switch away from carbohydrate to lipid metabolism as the
predominant source of energy. The provision of nutrients will
reverse these changes but administration that is either too rapid
or in an unbalanced form can result in dangerous shifts in elec-
trolytes and precipitate deficiencies in micronutrients. Patients
most at risk are those receiving enteral tube feeding or parenteral
nutrition, but care should also be taken with oral nutritional
supplements. The National Institute for Health and Clinical
Excellence (NICE) has specific guidance for managing these
complex patients.12 An intercollegiate working group, MARSI-
PAN (Management of Really Sick Patients with Anorexia Nerv-
osa), has produced guidelines on the medical and psychiatric
management of patients with anorexia nervosa.13
Assessment of nutritional status and diagnosis of malnutrition
Nutritional status is a composite concept, incorporating dietary
intake (what we eat), body composition (what we are) and
functional capacity (what we can do). Information is needed
about all these components.
Screening
Identification of patients at risk of malnutrition at an early stage
of hospital admission, or during attendance at the outpatient
Clinical features of classical re-feeding syndrome
Cardiovascular Cardiac failure
Pulmonary oedema
Dysrhythmias
Peripheral oedema
Electrolyte disturbance Hypophosphataemia
Hypokalaemia
Hypomagnesaemia (rarely hypocalcaemia)
Metabolic Hyperglycaemia
Neurological Wernicke’s encephalopathy
Confusion
Seizures
Hepatological Abnormalities in liver function
Musculoskeletal Rhabdomyolysis
Haematological Bone marrow dysfunction
Table 2
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 UNDERNUTRITION AND CLINICAL NUTRITION
Criteria for determining patients at high risk of
developing re-feeding problems12
The patient has one or C BMI less than 16 kg/m2
more of the following C Unintentional weight loss of greater
than 15% within the last 3e6 months
C Little/no nutritional intake for more
than 10 days
C Low levels of potassium, phosphate
or magnesium prior to feeding
The patient has two or C BMI <18.5 kg/m2
more of the following C Unintentional weight loss of greater
than 10% within the last 3e6 months
C Little/no nutritional intake for more
than 5 days
C History of alcohol abuse or drugs
including insulin, chemotherapy,
antacids or diuretics
Table 3
clinic, is a screening step to determine which patients need
formal assessment of nutritional status by a qualified trained
person, with a view to early intervention with nutritional
therapy. The Malnutrition Universal Screening Tool (MUST) is
a simple, rapid and easy method to screen patients and has been
shown to be reliable and valid.14 It aims to identify those at risk
by incorporating simple information which is collected routinely
for other reasons:
 current weight and height (BMI)
 history of recent unintentional weight loss
 likelihood of future weight loss.
Figure 3 provides a guide for using MUST e the total score has been
shown to be a better predictor of outcome than scores from the indi-
vidual components used in isolation, and identifies most patients who
have malnutrition.
The screening process identifies patients who require a more
detailed assessment, and formulation of an individualized stepwise
management plan by a nutrition specialist. Re-screening of in-patients
at 7-day intervals throughout a hospital admission alerts clinicians to
those who have lost weight and require greater intervention.
Detailed nutritional assessment
Full nutritional assessment to diagnose malnutrition is based on
mainly history and examination, with rather less emphasis on labo-
ratory investigations than is usual for most diagnostic processes.
Medical history
 Normal and varied recent dietary intake; an overview of daily
food intake, pattern of meals and portion size. Food
intolerance, allergies, religious or other restrictions. Specialist die-
tetic input is appropriate in patients where concern has been raised.
 History of recent intentional or unintentional weight loss.
Weight loss in obesity or in patients with oedema can be more
challenging to assess.
 Is the patient able to eat, swallow, digest and absorb sufficient
amounts of food to meet their requirements?
MEDICINE 39:1
 Are there any physical, medical, psychiatric or treatment
limitations that prevent patients meeting their requirements and
lead to weight loss?
 Does the patient have particularly high requirements for
certain nutrients (e.g. burns patients)?
 Does the patient have excessive nutrient losses, e.g. persistent
diarrhoea or enterocutaneous fistulae? Chronic pancreatitis can
cause malabsorption without steatorrhoea.
 Psychosocial history (e.g. recent social stress, social isolation,
previous eating disorders, alcohol consumption, prescription or
recreational drugs).
Examination
A focused examination should include:
 weight and BMI
 muscle wasting (e.g. appearance of temporalis)
 general condition of skin: fragile or dry
 general condition of mouth; presence of angular cheilitis and
mouth ulcers
 hydration status
 assessment of oedema.
Investigations
Most biochemical nutrient measures are acute-phase reactants, so
difficult to interpret. There are no specific laboratory tests to
‘diagnose malnutrition’. Blood tests can diagnose some specific
nutrient deficiencies (e.g. iron, folate, B12), provide supportive
information for monitoring and assessing specific electrolytes e.g.
magnesium. Low serum albumin is still commonly listed as an
indicator of malnutrition. Simple starvation does not suppress
serum albumin, but the presence of infection, or another inflam-
matory process reduces albumin more than in a well-nourished
patient. Low serum albumin thus usually implies reduced
synthetic capacity in the liver, which cannot be corrected by
increased protein or aminoacid supply. Bedside tests (e.g. mid-
arm muscle circumference, hand-grip strength and indirect calo-
rimetry) can be useful aids but are usually reserved for clinical
studies or departments with specialist interests, owing to the costs
of equipment, expertise required and time involved.
The diagnosis of malnutrition is very important. It must be
documented together with a management plan, coded and
included in discharge letters.
Management
All hospitals should have an established multidisciplinary
nutrition support team for managing patients with complex
nutritional problems. Within each organization there should also
be a nutrition steering committee to develop policies for nutri-
tional care, which should be regularly audited as part of clinical
governance frameworks.12
Individual patients’ needs vary enormously, depending on
their circumstances. The aim of nutrition support is to ensure
that total nutrient intake provides enough energy, protein, fluid
and micronutrients to meet the patients’ needs. In practice, the
majority of patients are managed by clinicians, nursing staff,
ward catering staff and dietitians, with more complex patients
having input from nutrition support teams.
In vulnerable patient groups the simple provision of regular
meals or food with better nutritional content may be enough to
48 Ó 2010 Elsevier Ltd. All rights reserved.
 UNDERNUTRITION AND CLINICAL NUTRITION

The Malnutrition Universal Screening Tool (MUST)

STEP 1 STEP 2 STEP 3

BMI score Weight loss score Acute disease effect score

BMI kg/m2 Score Unplanned weight loss in past If patient is acutely ill and there has
>20 (>30 obese) –0 3–6 months been, or is likely to be, no nutritional
18.5–20 –1 >20 (>30 obese) –0 intake for >5 days
<18.5 –2 18.5–20 –1 Score 2
<18.5 –2

STEP 4
Overall risk of malnutrition

Add scores together to calculate overall risk of malnutrition

Score 0: Low risk Score 1: Medium risk Score 2 or more: High risk

STEP 5
Management guidelines

0 1 2 or more
Low risk Medium risk High risk
Routine clinical care Observe Treat*
• Repeat screening: • Document dietary intake for 3 days if • Refer to dietitian, nutritional
Hospital, weekly; subject
1995 in hospital
1997 or care home
1999 2001 2003 support team or implement local
Care homes, monthly; • If improved or adequate intake – little policy
Community, annually clinical; if not improvement – clinical • Improve and increase overall
for special e.g. those >75 yrs concern – follow local policy nutritional intake
• Repeat screening: • Monitor and review care plan:
Hospital, monthly; Hospital, weekly;
Care home, at least monthly Care home, monthly;
Community, at least every 2–3 months Community, monthly

All risk categories Obesity

• Treat underlying condition and provide help and advice on • Record presence of obesity. For those with underlying
food choices, eating and drinking when necessary conditions, these are generally controlled before the
• Record malnutrition risk category treatment of obesity
• Record need for special diets and follow local policy

Re-assess subjects identified at risk as they move through care settings. A BMI of <20 kg/m2 (i.e. above the WHO BMI <18.5 kg/m2
cut-off for undernutrition) is used in the MUST score when screening patients who are unwell, to capture those whose weight is lower
than average (BMI 18.5–20) together with other criteria of undernutrition. In this setting it is more important to identify all patients
who are undernourished (high sensitivity) and less important to exclude false-positives from a dietetic assessment.

Figure 3

address nutritional risk. Additional measures may include broader
menu choices or providing assistance with feeding. Where these
‘social’ interventions are insufficient to ensure that nutritional
requirements are met, patients will need the addition of oral nutri-
tional supplements or enteral tube feeding, under dietetic supervi-
sion. Parenteral nutrition is rarely necessary, except in the context of
an inaccessible or non-functioning gastrointestinal tract.
Management of severe malnutrition includes initial resusci-
tation, to restore hydration, and replace electrolytes. Before
feeding starts, thiamine must be provided, to avoid Wernicke’s
encephalopathy when carbohydrate is consumed or fed (espe-
cially if there is a history of alcohol excess). Severely
malnourished patients are at risk of re-feeding syndrome, and
death. This risk is reduced if electrolytes are monitored closely,
and extra phosphate, potassium and magnesium are provided.
Nutritional replenishment will be successful in restoring body
composition and functional capacity sustainably, only if the
underlying cause can be removed or controlled. A persisting
inflammatory state (high WBC, CRP, TNF) is a major obstacle to
synthesis and re-growth of lean tissue, so surplus energy is stored
as fat, with little functional gain. Excess energy supply leads
rapidly to ectopic fat deposition especially in the liver, with
potentially fatal results. Attempts to increase appetite pharma-
cologically are seldom effective.

MEDICINE 39:1 49 Ó 2010 Elsevier Ltd. All rights reserved.

 UNDERNUTRITION AND CLINICAL NUTRITION
Malnutrition, clinical outcome and the health economics
The consequences of malnutrition for physiological function
have an important impact on clinical outcome. Malnourished
surgical patients have complication and mortality rates three to
four times higher than normally nourished patients, with longer
hospital admissions, and incur up to 50% greater costs. Similar
findings have also been described in medical patients, particu-
larly the elderly.15,16 It is often difficult to separate the delete-
rious effects of malnutrition from the underlying disease process
itself, especially because each can be a cause and consequence of
the other. However, there is clear evidence that nutrition support
significantly improves outcomes in these patients and it is vital
that malnutrition is identified through screening.
Malnutrition is also a major resource issue for public expen-
diture. The British Association of Parenteral and Enteral Nutri-
tion (BAPEN) have recently calculated that the costs associated
with disease-related malnutrition in 2007 in the UK were more
than £13 billion (greater than those associated with obesity). The
potential cost savings associated with the prevention and treat-
ment of malnutrition are considerable e a saving as small as 1%
represents £130 million per year. In specific situations, treating
malnutrition produces cost savings of 10e20% or more.17
Nutritional education
The importance of training medical students and junior doctors in
nutrition has been widely recognized; a report from a working
party of the Royal College of Physicians stated “Every doctor
should recognize that proper nutritional care is fundamental to
good clinical practice”.2 By addressing deficiencies in education of
all healthcare professionals and exerting influence through clinical
leadership there can be genuine improvements in nutritional care.
Learning objectives for Human Nutrition within Medical
Training have been published on-line by the Intercollegiate
Group on Nutrition, through its position within the Academy of
Royal Medical Colleges.18
Conclusions
Malnutrition has wide-ranging effects on physiological function
applicable to all disciplines of medicine, yet is often overlooked
by clinicians. It is associated with increased complications
resulting in increased morbidity and mortality in hospital in-
patients and significantly increased healthcare costs. Identifica-
tion of at-risk patients through better assessment and the use of
screening tools and efficient full assessment to make the diag-
nosis allows appropriate treatment to be instituted, which can
significantly improve clinical outcomes. A
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4 Russell C, Elia M. Nutrition screening survey in the UK in 2008.
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Practice points
C Malnutrition is a common, under-recognized and under-treated
condition in hospital patients.
C Disease-related malnutrition arises from reduced dietary
intake, malabsorption, increased nutrient losses or altered
metabolic demands.
C Wide-ranging changes in physiological function occur in
malnourished patients, leading to increased rates of morbidity
and mortality.
C Re-feeding syndrome is a serious and potentially fatal
complication, which is avoidable by careful consideration of
nutritional treatment.
C Routine nutritional screening should be undertaken in all
patients admitted to hospital using a validated tool such as
the Malnutrition Universal Screening Tool (MUST).
C Healthcare costs are significantly increased in malnourished
patients.
C The diagnosis of malnutrition is vital for medical, social and
medico-legal reasons.
50 Ó 2010 Elsevier Ltd. All rights reserved.