Malnutrition as a risk factor for patients in the hospital Malnutrition (under-nutrition) is defined as a nutritional state in which a deficit, excess, or imbalance of energy, proteins, and other substrates affects the morphological and functional condition of tissues and organs and influences the patient's clinical state. Under malnutrition, we include not only under-nutrition and obesity, but also deficiencies of individual micronutrients and macronutrients.

Types of malnutrition Protein-energy malnutrition is a consequence of imbalance between supply and requirement of proteins or energy substrates. Protein-energy deficit is often combined with, or with predominance of one of them. Predominantly energy deficit is known as marasmus, while predominantly protein deficit manifests as kwashiorkor. Marasmus is characterized by preserved relatively normal metabolism of nutritional substrates and energy, with predominant use of fat stores, and gradual weight loss that can progress to cachexia (Zadák, 2008, p. 193). Kwashiorkor is caused by inadequate protein intake or rapid protein breakdown, while the patient retains fat stores, whose volume is increased by interstitial seepage of retained fluid. For this reason, a patient with this type of malnutrition may appear well-nourished even when the patient is severely and life-threatened by undernutrition (Zadák, 2008, p. 193). A very serious situation is the combination of malnutrition with injury, severe disease, or major surgery, leading to worsening catabolism. Although nutrition at that moment cannot reverse catabolism into anabolism, it can mitigate the effects of the acute state and become life-saving (Grofová, 2007, p. 69).

Numerous studies have confirmed that malnutrition is an independent risk factor leading to increased morbidity, longer hospitalization, a higher number of readmissions, longer convalescence, worsened quality of life, and increased mortality. Its economic consequences related to treatment of complications are also substantial (Satinský, 2009, p. 409). Its prevalence varies depending on available literature, but it clearly depends on how diagnosis is performed and on the rigor with which healthcare systems in different countries record it statistically. According to Zadák (2008, p. 191), prevalence of malnutrition among hospitalized patients ranges from 19–80%, with 30% of patients having iatrogenic malnutrition and in 3–4% of patients the severity is so high that without adequate nutritional support it results in death. Alarming is also the figure that in 70% of patients, hospitalization leads to worsening of pre-existing malnutrition.

Risk patient groups for the occurrence or worsening of malnutrition include:

  • patients with oncological disease - 85%,
  • patients with inflammatory bowel diseases - 80%,
  • critically ill patients - 65%,
  • patients with chronic diseases of the respiratory system - 45%,
  • geriatric patients - 50% (Zadák, 2008, p. 191).

The presence of malnutrition may be indicated by unintended weight loss of 10–15% over 6 months, BMI < 18.5, stage C by Subjective Global Assessment or Nutrition Risk Screening value ≥ 3, serum albumin < 30 g/l. According to Firment et al. (2010, p. 9), serious nutritional risk is represented by the presence of any one of the above markers.

The etiology of malnutrition is multifactorial. In non-hospitalized patients, the factors are age, the presence of chronic diseases, socioeconomic status, and unintended body weight loss. In hospitalized patients, risk factors are basic and comorbid diagnoses, anatomical and functional conditions of the digestive tract, pain, high temperature, dehydration, pressure ulcers, oncological treatment, polypharmacy, frequent diagnostic and therapeutic procedures requiring fasting, and reluctance to accept hospital meals. To the worsening of existing malnutrition may also contribute inadequate assessment of nutritional risk resulting from the nature of the acute condition, its severity, and the need for invasive diagnostic and therapeutic procedures. Other reasons include:

  • patient refusal of food,
  • management of diagnostic and therapeutic interventions requiring fasting before or after the procedure,
  • insufficient monitoring of the amount of consumed food in selected patient groups (geriatric patients, patients with dementia, patients with eating disorders, diabetics),
  • insufficient monitoring of complications that can lead to worsening malnutrition (diarrhea, vomiting, febrile state, abdominal pain, consciousness disorders...).

Morphological and functional changes in malnutrition

Each significant malnutrition affects organ functions and structure. In approximately 45% of patients, malnutrition increases complication rates, prolongs hospital stay, and raises the economic cost of treatment. Ultimately, severe acute illness in a malnourished patient can result in multiorgan failure and death. Gastrointestinal tract - after 7 days of insufficient oral intake (earlier in critically ill patients), damage to the GI tract occurs; integrity disturbances of the intestinal wall arise, and this altered GI tract becomes a source of proinflammatory processes. Lack of luminal nutrition leads to reduced enzyme secretion and disruption of their function, stasis of intestinal contents, overgrowth of potentially pathogenic microorganisms, increased absorption of toxins, reduced intestinal perfusion, microvillus atrophy, altered nutrient absorption, increased intestinal permeability, and loss of reabsorptive capacity of the colon. In experimental settings, lack of luminal nutrition leads to intestinal atrophy, which causes loss of barrier function and translocation of intestinal bacteria and toxins through lymph nodes into circulation (Bátovský, 2013, p. 6). Cardiovascular system - loss of myocardial mass results in reduced contractility, reduced cardiac output, bradycardia, and in advanced stages hypotension. In severely malnourished patients, cardiac or circulatory failure may occur. Respiratory system - a 20% loss of respiratory muscle proteins leads to changes in both muscle strength and structure, reduced ventilation, and disorders of innervation of breathing muscles. Patients suffer from hypoxia and hypercapnia, less ventilated lung regions become poorly aerated and prone to infection. Reduced muscle strength is the reason a patient cannot cough effectively, which leads to atelectasis and increased risk of bronchopneumonia. Central nervous system - tendency to depression and anxiety may be a manifestation of brain damage. Marked mental disorders and peripheral nervous system disorders are often the consequence of ionic imbalances and deficiencies of various micronutrients. Immune system – impaired cellular and humoral immunity increases infection risk; healing of acute and chronic wounds is complicated. Renal function – hypoperfusion leads to renal atrophy, worsening of concentrating ability, reduced glomerular filtration, disturbances in fluid and electrolyte balance, and even acute kidney failure. Thermoregulation – reduced body temperature caused by increased heat losses and reduced heat production for energy reasons lowers core body temperature by 1–2 °C, leading to central nervous system disturbances, confusion, and muscle weakness. Tolerance to cold is also impaired due to disturbed vasoconstriction (Zadák, 2008, p. 213).

Diagnosis of malnutrition

Nutritional assessment is a multidimensional and dynamic evaluation that is part of the overall clinical assessment of the patient. There is no single method by which one can unambiguously identify the presence and severity of malnutrition. Multiple investigations must be performed and obtained parameters should be interpreted in the context of the patient's overall clinical state and individual organ functions.

To assess the degree of catabolism and determine patient reserves, the following set of examinations is recommended:

  • clinical examination,
  • basic anthropometric measurements,
  • biochemical, hematological, and immunological testing,
  • evaluation of energy and protein intake and output,
  • functional tests,
  • assessment of nutritional status score, disease burden, and nutritional risk (Zazula et al., 2006, p. 12).

While in Slovakia nutritional status assessment is not part of patient health status evaluation at admission to healthcare facilities, in the United Kingdom, USA, the Netherlands, and Denmark, nutritional risk screening is a mandatory part of initial examination of every patient and a condition for accreditation. According to Voleková et al. (2013, p. 9), patients admitted to hospitals for acute diagnostic or therapeutic interventions do not have time for major correction of malnutrition. It is therefore even more important to quickly identify patients whose reserves have been depleted due to deficient nutrition and for whom acute illness, injury, or surgery associated with stress would mean further mobilization of molecules from their own tissues. Early diagnosis of malnutrition is a prerequisite for selecting an appropriate nutritional strategy to address it.

Management of malnutrition in healthcare facilities

Nutritional support is considered treatment with all attributes of pharmacotherapy, and failure to provide it or incorrect provision is a non-ideal practice (Bátovský, 2013, p. 6). It is an integral part of comprehensive therapeutic, preventive, and nursing care. Risks arising from insufficient energy and nutritional intake are comparable to inadequately provided medical treatment. Calculation of energy needs and determination of nutritional composition based on nutritional risk and state, prescription of nutrients and possibly pharmaconutrients, choice of a suitable strategy for managing malnutrition, and monitoring of clinical status and complications require an interdisciplinary approach with clearly defined competencies and accountability. Therefore, in the Slovak Republic, nutritional teams are established in teaching and specialized hospitals, whose tasks include, among others, overseeing timely identification of nutrition-risk patients and the adequate and cost-effective use of each type of clinical nutrition in managing malnutrition. The organization of clinical nutrition is guided by the 2009 Bulletin of the Ministry of Health of the Slovak Republic - professional guidance of MZ SR, which amends and supplements the professional guidance of MZ SR No. 13168/2006 OZS on the organization of clinical nutrition. It emphasizes the importance of appropriate nutrition in disease treatment and its influence on therapy effectiveness and prognosis. The Bulletin also defines forms of malnutrition treatment and sets criteria for which patients are entitled to nutritional care. According to the guidance, for patients who cannot or should not be fed by mouth, enteral or parenteral nutrition is indicated.

Enteral and parenteral nutrition Enteral nutrition (EN) is defined as a complete and balanced liquid diet with a precisely specified content of macro- and micronutrients, administered into the GI tract by routes other than normal oral intake. According to Desatová et al. (2013, p. 12), its advantage over parenteral nutrition is that it feeds the gut. Through immunomodulatory effects, it positively supports maintenance of physiological intestinal microbiota and barrier function, helps prevent villous atrophy, improves antioxidant status, stimulates intestinal motility, and stimulates secretion of gastrointestinal hormones. Equally important is its lower cost and less severe complications compared with parenteral nutrition. In patients for whom natural feeding is not possible, we choose one of the following methods of EN administration:

  • nasogastric/orogastric tube,
  • nasojejunal tube,
  • percutaneous endoscopic gastrostomy/jejunostomy,
  • surgical gastrostomy/jejunostomy,
  • feeding button.

Sipping, drinking oral nutritional supplements, is an EN administration route indicated in patients for whom normal oral intake cannot fully cover nutritional and energy demands for any reason. Clinical nutrition preparations intended for sipping can be fortified with selected micro- and macronutrients and are used in treatment of specific health conditions. If enteral nutrition is contraindicated, or cannot fully cover a patient's nutritional requirements, parenteral substitution is needed. Parenteral nutrition (PN) is a method of delivering nutrients directly into the vascular system by bypassing the digestive tract. If a patient’s nutritional and energy requirements are fully met parenterally, this is total parenteral nutrition. If a patient is also taking food orally or enterally, this is supplemental parenteral nutrition. In cases requiring short-term nutrition, a peripheral vein is cannulated. Maximum recommended osmolality is observed, and nutrition is generally not given for longer than 7 days. It is not suitable for patients with high energy demands, the need to infuse larger fluid volumes, and for long-term nutritional support (Zadák, 2008, p. 221). When infusion solutions with high osmolality are needed, administration of PN through a catheter in a central vein is preferred. A central venous catheter allows administration of concentrated solutions with lower volumetric loading of circulation. It is suitable for patients with renal and hepatic failure, ARDS (acute respiratory distress syndrome). If parenteral nutrition is indicated for a long period, it is advantageous to use a so-called tunneled catheter or a venous port.

Systemic measures to prevent iatrogenic malnutrition

Prevention of malnutrition arising in connection with hospitalization begins with early detection of malnourished patients and assessment of risks associated with hospitalization. The patient should be informed about the reasons for limited oral intake or prescribed special diet or unusual mode of feeding. A reason why food remains untouched on the plate may be the patient’s mental state, poorly fitting prosthesis, swallowing disorder, impaired mobility, or overall weakness. Sometimes it is enough to position the patient appropriately, use special utensils, adjust food consistency, assist with feeding, and explain the importance of dietary restrictions. In one study (Jefferies et al., 2011), patients were often exposed to prolonged and repeated periods of zero oral intake associated with waiting for various diagnostic and therapeutic procedures requiring fasting. In addition to coordinating these, preventing malnutrition could also be supported by improving patient access to food outside meal times, and by preventing interruptions during feeding caused by various nursing and medical procedures. Attention should also be paid to monitoring complications leading to worsening malnutrition and treating them promptly.

Benefits of high-quality nutritional care

Nutritional care as part of comprehensive care significantly influences the treatment process, especially in the treatment of severe acute and chronic diseases. It is one of the key factors increasing the effectiveness of therapy of the underlying disease and also the body's ability to tolerate demanding treatment, such as oncological therapy or the convalescence period after major surgery. It stimulates the immune system, helping to prevent infectious complications, improves wound healing, reduces the risk of reoperations and pressure ulcer formation. In patients with inflammatory bowel diseases, it improves nutrient absorption and mucosal healing; in patients after surgery of the femoral neck, it reduces bone mass loss and increases its density; in patients with respiratory diseases it covers increased energy demands and reduces CO2 production, and in ventilated patients it shortens the duration of mechanical ventilation. Adequate nutrition improves muscle strength, contributes to improved quality of life, has a positive effect on mental state, and supports early return to active life.

Conclusion

Provision of nutrition is among the fundamental biological needs of a person. Nutritional care at the interface of medical, nursing, and dietary care significantly influences the treatment process, especially in the treatment of severe acute and chronic diseases. It is one of the key factors increasing the effectiveness of therapy of the underlying disease and the body's ability to cope with stressful situations.

Authors: PhDr. Eva Balogová, doc. PhDr. Jana Boroňová, PhD. List of bibliographic references

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