Malnutrition:

Definition, Prevalence,
Outcomes, and Cost
What is Malnutrition?
Malnutrition = “undernutrition”
• Inadequate intake of energy, protein and other nutrients
• Obese malnourished: excess fat stores but micronutrient or
macronutrient (typically protein) malnourished
• Sustained inadequate intake leads to functional change in
tissues of the body e.g. muscle loss, weakness, immune
function, capacity for recovery, cognition
• Responds to re-feeding
• Inflammation (disease) can influence response to re-feeding

CMTF website adapted from: AW McKinlay:

Malnutrition: the spectre at the feast. J R
Coll Physicians Edinb 2008:38317–21.
Diagnosing Malnutrition
Subjective global assessment (SGA) is the gold standard for diagnosing
malnutrition in hospital.

Classification:

A: Well nourished: no history or physical findings of malnutrition

B: Moderately malnourished: Weight loss 5-10% of usual body weight;

unintentional weight loss (6 months); mild/moderate signs of malnutrition

C: Severely Malnourished: Unintentional weight loss > 10% usual body

weight (past 6 months); severe signs of malnutrition

*SGA specifically assesses for protein-energy malnutrition and not micronutrient

malnutrition
 Malnutrition

Morbidity  Mortality 
Wound healing
Infections  Treatment 
Complications 
Convalescence Length of Stay 

Quality of Life
COSTS 
Suffering 
Human Costs of Malnutrition
Negative outcomes associated
with malnutrition
 Delayed wound healing
 Impaired immunity
 Lower quality of life
 Impaired function
 Increased length of stay,
readmission, mortality and/or
morbidity rates

Correia M.I. Et al: Clin Nutr. 2003; 22:235-9.; Covinsky K.E. et al: J Am Geriatr Soc. 2002; 50:631-7.;
Middleton M.H. et al:. Intern Med J 2001;31:455-61.; Ferguson M. et al. J Am Diet Assoc 1998;98
(suppl.): A22. Suominen M et al. Eur J Clin Nutr 2005; 59: 578-583.; Neumann SA et al. J Hum Nutr
Dietet 2005; 18: 129-136.; Norman K et al. World J Gastroenterol 2006; 12: 3380-3385.; Pauly L et al. Z
Gerontol Geriatr 2007; 40: 3-12.; Keller H, Can J Rehab 1997; 10(3): 193-204; Keller H, J Nutr Elder
1997;17(2):1-13.
 Increased Mortality
50
PEM non-PEM
44% mortality in
malnourished 40

patients after 9
% Mortality
30
months vs. 18%
in well-nourished 20
patients
10

0
0 1 2 3 4 5 6 7 8 9
Months After Hospitalization
PEM: Protein Energy Malnutrition

Cederholm T et al. Am J Med. 1995;98:67-74.

The Costs Associated with
Malnutrition
Malnutrition at admission extends length of stay by
~3 days = $1500-2000 CAD / patient (Curtis et al, 2016)
Admitted malnourished patients…
• Cost ~60% more than well nourished patients (Braunsweig et al,
2000; Correira et al, 2003)
• This cost is independent of disease state (Lim et al., 2012)
• Length of stay (LOS) 2-6 day longer (Correira et al., 2003; Kyle et al., 2004;
Pirlich et al., 2004)
• Developing malnutrition during hospitalization results in
even longer LOS ~15 d (Álvarex-Hernández et al., 2012)
• 2 x increased risk of readmission in 2 weeks (Lim et al., 2012)
• Increased two-year mortality 7 fold (Lim et al., 2012)
Length of Stay and Readmission
• Being severely malnourished (SGA C), low hand
grip strength (HGS) and reduced food intake
during the first week of hospitalization
independently predicted a longer length of stay
• SGA C and HGS were independent predictors of
30-day readmission

Jeejeebhoy KN, 2015 AJCN

Is Treatment Effective?
Generic Oral Nutritional Supplementation(ONS)
(Phillipson et al., 2013)
• 1.6% of 44 million hospital visits used ONS
• ONS use decreased LOS by 21%; ~$ 4734
USD/patient savings
 Scoping review: food first interventions (Cheung et al., 2013)
• Individualized RD treatment  improved intake
and health outcomes
• protected mealtimes, eating assistance 
improves food intake
Implementation of guidelines in ICU (Doig et al., 2008; Martin et al.,
2004)
• Early nutrition support improves outcomes
Malnutrition Research in Canada
• The Canadian Malnutrition Task Force (CMTF)
conducted the Nutrition Care in Canadian Hospitals
(NCCH) cohort study (2010-2013).
• The NCCH study provides evidence to support best
practice for prevention, identification and treatment
of malnutrition in hospitals from 18 hospitals across
Canada.
• Many of the results shown in this presentation are
from the NCCH study.
Hospital Malnutrition in Canada
• Almost 1 in 2 medical or surgical patients who stay 2+
days are malnourished at admission (Allard et al., 2015)
• Less than ¼ of patients see a dietitian, most of these
patients are not malnourished; 75% of malnourished are
missed (Keller et al., 2015)
• Patients who deteriorate have a longer length of stay
(medical 18 days; surgical 12 days) (Allard et al., 2016)
• 2/3 of patients leave in the same nutritional state as
admitted while 1 in 5 gets worse (Allard et al., 2016)
Hospital Malnutrition in Canada
• Poor food intake (≤50% of tray) in the first week of
hospital stay occurs for ~35% of patients (Allard et al., 2015)
• Poor food intake during admission predicts length of
stay when adjusted for other covariates such as
malnutrition at admission (Allard et al., 2015)
• Patients experience many barriers to intake (Keller et al.,
2015)
• 42% interrupted during meal
• 69% if missed a meal, not provided food
• 30% couldn’t open food packages
• 20% could not reach meal tray
 Prevalence of Malnutrition in
Hospital
• Reported prevalence of malnutrition among hospitals in North
America and Europe: 20% to 60%.
• The prevalence of malnutrition at admission is reported at 45% in
acute care hospitals in Canada (Allard et al, JPEN 2015).

11.43%
Prevalence based Well Nourished (n=558)
on SGA
Moderate Malnutrition
(Based on Nutrition
33.60% 54.98% (n=341)
Care in Canadian
Hospitals Study) Severe Malnutrition
(n=116)
What predicts length of stay?
(Nutrition Care in Canadian Hospitals Study, Allard et al., JPEN 2015)

Characteristics Hazard 95% CI All of these factors, except a higher

Ratio hand grip strength, predict a longer
SGA* B/C 0.73 0.62, 0.86 length of stay.
Hand grip strength 1.12 1.01, 1.23
This means that malnutrition (SGA
Nutrition support 0.61 0.42, 0.88
B/C), taking into account diagnoses,
Food intake ≤50% 0.73 0.62, 0.87
age and other covariates adjusted for
Male 0.77 0.63, 0.93 in this analysis, predicts length of
Lives in “other” setting 0.72 0.53, 0.96 stay.
Number of diagnoses
2 0.70 0.59, 0.84 Food intake regardless of nutritional
3 0.58 0.44, 0.76 status also predicts length of stay
Number of meds 0.96 0.95, 0.98 when adjusting for covariates
including nutritional status.
HR > 1.0 characteristic predicted shorter length of stay HR < 1.0 predicted a longer length of
stay. Adjusted for: cancer, type of unit, CCI, education, age, RD visit, NPO for 3+ d, preadmission
wt loss, BMI at admission
 Change in Nutritional Status and
Length of Stay
(Nutrition Care in Canadian Hospitals Study, Allard et al. Clin Nutr 2015)
(Admission vs. Discharge n=409 who stayed 7+ days)

SGA Stable Deteriorated Improved

Well nourished 9d 10 d N/A
Mild/mod mal’n 9.5 d 21 d 10.5 d
Severe mal’n 12.5 d N/A 12.0 d
Summary
• Prevalence of malnutrition in medical and surgical
patients who stay 2+ days in Canadian hospitals is
45%
• Nutritional status deteriorates in hospital for some
• Food intake ≤ 50% and malnutrition are key predictors
of length of stay
• Malnutrition is costly in human and financial terms
• A malnourished patient costs $1500-2000 CAD more
• Treatment improves outcomes
Moving Forward…
• All health care professionals need to be concerned
about the nutritional status of patients

• All health care professionals need to…

• Become “Food Aware”
• Recognize that “Food is Medicine. Medicine Heals.”
Acknowledgements
These slides were created
and approved by:

Heather Keller
Celia Laur
Bridget Davidson
The More-2-Eat Education
Group*

* Includes input from the UK Need for

Nutrition Education/Innovation
Programme (NNEdPro) Group

This research is funded by Canadian Frailty Network (known previously as

Technology Evaluation in the Elderly Network, TVN), supported by Government
of Canada through Networks of Centres of Excellence (NCE) Program