Increase in malnutrition among patients entering hospital

Increase in malnutrition among patients entering hospital

Patient nutrition now better managed within hospitals

Mandatory malnutrition screening should be extended to all oncology settings

More than a third of patients are malnourished when being admitted to hospitals in Ireland and the level is increasing – according to a new survey being launched today by the Irish Society for Clinical Nutrition and Metabolism (IrSPEN).

The survey carried out in November 2023 with data from 3,662 patients across 26 public hospitals in Ireland found an increase in hospital admission malnutrition to 34%, compared to previous surveys in 2011 (32%) and 2010 (28%).

However, it also found a significantly reduced rate of malnutrition in patients in long stay or rehabilitation wards, 21% compared to 36% on all other wards, and also in those admitted from other hospitals rather than from home at 26% compared to 35%.

This showed that mandatory national malnutrition screening and treatment protocols introduced in public hospitals in 2020 are working.

Launching the National Malnutrition Screening Survey 2023, IrSPEN is calling for malnutrition screening to be expanded to other clinical settings such as in outpatients, daycare and primary care settings, particularly for cancer patients and frail older people.

Report Co-author and IrSPEN Director Niamh Rice said the survey identified two major reasons for the rise in patients with risk factors for malnutrition: “The first is an increase in the age demographic of patients presenting at hospitals, with older people more likely to be malnourished and secondly a higher incidence of cancer, resulting in more cancer patients within the general hospital population (22% in November 2023 versus 16% in 2011), with this patient cohort also more likely to suffer nutritional problems resulting in malnutrition.

“The level of malnutrition presenting at our public hospitals remains too high and some is preventable if we pay more attention to improving the nutritional status of patients in the community. We need to expand screening and treatment for malnutrition to all settings where cancer patients receive care, particularly in day wards where they receive systemic anti-cancer therapy (SACT), to facilitate rapid access to specialist cancer dietitians, of whom we have just a handful across the country.

“A secondary recommendation is to resource an expansion of targeted malnutrition screening and treatment for older people living with frailty, particularly those living alone and requiring home care support.

“These patients typically present to their GP and to hospital emergency departments more frequently, and at significant cost to the healthcare system, due to falls and an increasing need for care. In many cases, loss of muscle due to increased nutritional requirements or poor dietary intake – malnutrition – is a key factor resulting in poorer quality of life, increasing frailty and an increased healthcare costs.”

IrSPEN has also today made a 2025 pre-budget submission on these recommendations – calling for additional malnutrition interventions to be supported and funded.

Meaning of malnutrition

Co-Author and King’s College London Lecturer & Cancer Research Dietitian Dr. Erin Stella Sullivan RD, said there is also a lot of confusion regarding what malnourished means, which she knows first-hand from supporting patients with cancer.  

“It is often incorrectly thought of as meaning being underweight or ‘skinny’. However, if patients are not eating what they need during illness, muscle is broken down in an attempt to keep the tissues supplied with the protein building blocks needed to keep everything functioning normally. This happens even if patients have higher BMI and can even be hidden in those cases.

“The effect of a screening and treatment programme is that patients who are losing weight or failing to eat sufficient protein, energy or other nutrients, which are typically required in higher amounts during illness – are identified early, so that appropriate nutritional supplementation or support can be provided.

“The impact of an improved nutritional status is significant health gain for these patients – improving their resilience, ability to complete treatment courses and enhancing their quality of life. There are also benefits to the healthcare system as healthier, stronger patients, have fewer complications and better outcomes.”

Screening works

A welcome finding in the survey is significantly lower rates of malnutrition in hospital long-stay patients (21% in 2023 compared 35% in 2011), pointing to the impact of mandatory malnutrition screening and treatment protocol in all public hospitals, following introduction of National Clinical Guideline 22 in 2020.

Ms Rice said: “Thankfully this points to Ireland bucking the international trend of worsening nutritional status within hospital patients. We need to build on this positive impact and expand it into other settings targeting those which the survey has identified as most at risk.”

Further survey details:

1. Older people now represent 15.6% of our population, at 806,300 over 65s in 2023, an increase of 50% since 2011, when the last survey of malnutrition in hospitals was conducted. This upward shift in median age of the inpatient population, explains the higher prevalence of malnutrition in those entering the hospital system, since old age is an independent risk factor for disease related malnutrition.

2. The higher proportion of patients reported to have cancer (one in five in the survey) is also a significant contributor to malnutrition rates on entry into hospital, with the risk of malnutrition detected in 44% of those with cancer, versus 30% of those without, irrespective of age.

3. Lower rates of malnutrition in those admitted from other hospitals and in rehabilitation or long stay hospitals is very positive and reflects improvements in nutritional care, from earlier detection on point of entry into the hospitals due to screening and better follow through with appropriate nutrition support (from oral nutrition support to tube feeding or even intravenous / parenteral nutrition where needed).

The survey was carried out by IrSPEN with the support of the Irish Nutrition and Dietetic Institute (INDI) which is the professional organisation for registered dietitians in Ireland. The National Malnutrition Screening Survey Republic of Ireland 2023 is available to view HERE