Reduce the Prevalence of Specific Conditions by the use of Screening and early Diagnosis of Malnutrition

Rolf Smeets, PhDVP Medical

Who is malnourished?

They are all malnourished!

What is malnutrition?

“A state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients (e.g. vitamins) causes measurable adverse effects on tissue/body form and function and clinical outcome”

Elia, 2000

In this presentation, the focus is undernutrition.

In Europe most malnutrition is caused by disease and occurs across all age groups, but particularly in the older person. It is often overlooked and incorrectly considered “normal” or “inevitable” in illness or older age.

Malnutrition has far-reaching consequences

Impaired ability to fight infection

Reduced mobility

Apathy, depression

Impaired wound healing

Reduced quality of life Greater mortality

More GP visits and hospital admissions

Reduced ability to work,shop, cook, self-care

Reduced muscle strength

and fatigue

↓ Activity↓ Walking

Speed ↓Strength &

Power

Sarcopenia

Frailty

Neuroendocrine Dysregulation

Anorexia of aging

Aging: Senescent musculoskeletal

changes

Weight LossNegative Energy Balance

Negative Nitrogen Balance

Disability

Dependency

Chronic Undernutrition

(Inadequate intake of protein and energy; micronutrient deficiencies)

↓ Resting Metabolic Rate

Disease

↓ Total Energy Expenditure

Central role of Undernutrition in function

Prevalence of sarcopenia in elderly

Melton et al, 2001; Jansen et al, 2002 (NHANES III); Paddon-Jones 2009

30% of individuals over 65y and 50% older than 80y

Malnutrition is prevalent in hospitals across Europe

• Older people are particularly at risk: 40% greater risk in patients aged >65 years than <65 years¹

¹ Russell and Elia, 2009

Large surveys show malnutrition is a substantial problem in many European countries

e.g. in the Netherlands

“In general, one in every five patients was malnourished”

Hospitals: 14.8%Nursing homes: 18.5%

Home care: 13.9%

Total survey n 20,255 Hospitals: 6021

Nursing homes: 11902 Home care: 2332

Meijers et al, 2009

Malnutrition is not just a hospital problem

Most (93%) individuals with malnutrition are free living in the community, risking losing their independence.

HospitalsSheltered HousingCommunityCare homes

Elia et al, 2009

Malnutrition is a growing problem for Europe

• In the UK over 3 million people estimated to at risk of malnutrition

– Represents approx. 5% of the population²

• In Europe 33 million people estimated to be at risk of malnutrition (20 million in the EU)

²Based on UK population of 61,383,000 in mid-2008: http://www.stastistics.gov.uk/cci/nugget.asp?!ID=6

Elia and Russell, 2009; Ljungqvist and de Man, 2009; Ljungqvist et al, 2010

Estimated cost of malnutrition across Europe

• Europe: €170 billion per year • EU: €120 billion per year

Ljungqvist and de Man, 2009; Ljungqvist et al, 2010

Despite being common and costly, malnutrition is under the radar

Large survey shows malnutrition is under–detected and under-treated in the Netherlands

“Nutritional treatment was applied fewer than 50% of

all malnourished patients in nursing homes, hospitals

and home care.”

Total survey n 20,255Hospitals: 6021

Nursing homes: 11902 Home care: 2332

Meijers et al, 2009

How can malnutrition be managed?

• Early identification is key to effective management of malnutrition

• A range of strategies can be used to manage malnutrition e.g. dietary advice, oral nutritional supplements (ONS), tube feeding or parenteral nutrition (intravenous nutrition)

* Based on ESPEN definition, 2006

Appropriate management can save costs in malnourished hospital patients

• Retrospective cost analysis of 9 trials with and without use of appropriate dietary management:– mean cost savings of between €407 (£352) and € 9458 (£8179)

per patient in surgical, orthopaedic, elderly and cerebrovascular accident patients

• Cost savings also demonstrated in other patient groups:Patient group Country Cost saving per patientOlder patients at risk of developing pressure ulcers (Stage IV)

UK €532 (£460)

Pooled results from analysis in surgical, elderly and stroke patients

UK €982 (£849) (bed day costs)€345 (£298) (complication costs)

Abdominal surgery patients

The Netherlands €252 (£218)

Stratton et al, 2003; Elia and Stratton, 2005; Elia et al, 2005; Nuijten and Freyer, 2010

Implementing a malnutrition screening programme improves care and outcome

• More patients screened• Significant increase in use

of appropriate nutritional care plans

• Reduced health care use and costs

• Training and education• Practical sessions on

screening• Care plans devised and

agreed• Record charts and

monitoring

Cawood et al, 2009

Implementation of screening

Improved nutrition

Example of best practice, NICE shared learning website

EU urges to introduce routine screening protocols for malnutrition across Europe

"Malnutrition requires a cross-cutting solution; a good first step would be mandatory nutrition risk screening

across Europe, on which I will encourage my colleagues to adopt a

parliamentary resolution."

Alojz Peterle, MEP, co-chair ENVI Committee, November 2010

Leading nutrition experts and policy makers urged governments to do more

to tackle malnutrition in Europe by making nutrition an "integral" part of public health policies and disease

management programmes for chronic and rare diseases.

They also called for comprehensive nutrition guidelines for all healthcare and social-care professionals, and

demanded that healthy hydration be built in to good nutritional care.

Main barriers for implementation of effective screening

Proportion of respondents (%)

Reason Hospital Nursing home GP practice

No interest by senior management / GP

61.5% 66.7% 75.0%

Unclear responsibility 57.7% 33.3%

Screening done but not followed up

50.0% 16.7% 4.2%

Lack of staff for screening 38.5% 45.8%

Lack of agreement on screening tool

26.9% 16.7%

Other 19.2% 8.3% 8.3%

No equipment available 11.5% 25.0%

Not feasible to make required measurements

7.7% 12.5%

No time 0.0% 0.0% 58.3%

Too expensive 0.0% 0.0% 0.0%

Proposed Partners

• Scientists• Scientific organisations• Patient associations• Health care professional organisations• Industry groups• Government and policy makers• Insurance companies• ……..

• E.g.: ESPEN, ENHA, MNI, EUGMS, IAGG, HOPE, EFAD

Summary

• Clinical and economic effects of malnutrition are well documented

• For individuals and society, the biggest challenge remains that malnutrition is undiagnosed and under-treated

• Implementing screening linked to an evidence-based plan for the management of malnutrition is fundamental across health and social care settings

• Appropriate management of malnutrition improves nutritional care and improves outcome and reduces health care costs