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October 23, 2014

Nutrition cannot be targeted in cutbacks

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Aoife Connors speaks to Dr Mike Stroud on the importance of treating malnutrition properly and how nutrition should remain a priority, despite economic cutbacks


Proper treatment of malnutrition reduces costs from hospital stays, GP
consultations and long-term care needs of vulnerable groups such as the elderly – and during these recessionary times, nutritional budgets ‘should actually be something that’s improved’, according to a top UK gastroenterologist.
There is a common misconception that malnutrition is not a problem in modern
healthcare settings, Dr Mike Stroud, a consultant gastroenterologist and senior lecturer in medicine and nutrition in the UK told IMT.
In fact, malnutrition is very common in Ireland today as a result of anorexia, illness, poor mobility, poverty and social isolation.
Dr Stroud was the special guest speaker at the IMT Practice Management Seminar, which was held in Cork on 15 May.
The gastroenterologist describes malnutrition as under-nutrition affecting a
person’s health, wellbeing and ability to work.
As a population, malnutrition has always been present. “We’re not more malnourished today than before; however, the condition has been completely overlooked. Good nutrition is essential. It’s amazing that something so fundamental to medical care is so neglected and dismissed within the system,” he said.
“Most doctors don’t know very much about nutrition and it always amazes me.
”Malnutrition is under-recognised and under-treated. It weakens the immune system, leading to increased GP visits, prolonged illness and hospitalisation.”
Causes of malnutrition
Malnutrition builds up over time, said Dr Stroud. It can be due to an underlying disease that suppresses the appetite or because the body cannot utilise food properly. The illness can be caused by immobility, depression or social isolation. It leads to poor immunity as the response of the white blood cells deteriorates at fighting infection.
“The muscle and respiratory strength declines by 15 per cent because the body goes into a conservative mode very quickly.”
Malnutrition can also lead to renal dysfunction with loss of ability to excrete sodium and water. This causes impaired gut integrity and immunity and impaired wound healing. It can cause liver fatty change with a functional decline in necrosis and fibrosis and possible psychological effects leading to depression and apathy, Dr Stroud explained.
A study comparing non-malnourished patients with people suffering from disease-related malnutrition, with a BMI <20kg/m2, showed malnourished patients had a 6 per cent higher GP consultation rate and required 9 per cent more prescriptions.
These patients also had a 25 per cent higher hospital admission rate (Martyn 1998). Dr Stroud said that amongst the elderly in the UK, between 3-6 per cent of free-living and up to 16 per cent of institutionalised individuals are considered to be at risk of suffering from malnutrition (BMI <20) and the incidence of specific micronutrient deficiencies is even higher.
Another study focused on patients preparing for major abdominal surgery for cancer.
There were well-nourished and malnourished groups of patients. The malnourished patients had three times more complications and were four times more likely to die due to complications during and after surgery (Meguid et al., Am j Surg 156, 1988).
There was a 70 per cent reduction in complications in those that are nutritionally well compared to those malnourished. Malnourished patients stayed in hospital for almost a week, but those nourished were likely to stay two-thirds of a day less, which means huge savings in the healthcare budget, Dr Stroud said.
Malnutrition must be addressed before surgery, to prevent a patient losing
10 per cent of their body weight. He said, “If you have a stroke, the defences weaken by 10-15 per cent and you become irritable and withdrawn if you stop eating for three days, so a nutritional supplement is required.”
Dr Stroud said, “Doctors don’t notice malnutrition very much but surgeons do, because patients’ wounds may open if they are malnourished and their figures become quite poor.”
Dr Stroud pointed out that although increasing numbers of people may be overweight or obese today, it is becoming increasingly easy to miss malnutrition. “It’s easy for doctors and other healthcare professionals to look at someone overweight and think they’re not malnourished, but actually they haven’t been eating well for seven days or even for weeks.” He added: “It is a strange position that you might be thinking of giving them some nutritional support and yet they are overweight.”
Treating malnutrition
Dr Stroud is Chairperson of the British Association for Parenteral and Enteral Nutrition (BAPEN) a multi-disciplinary organisation established to raise awareness about malnutrition and the options for nutritional treatment.
He is leading a drive in Britain at the moment by BAPEN to highlight the impact of malnutrition on health budgets and resources ‘to ensure that healthcare does take into account the importance of malnutrition’.
“I would anticipate that the current excess healthcare costs around malnutrition in Ireland are probably in the order of €1 billion, I would imagine you could save 10 per cent by addressing malnutrition – that’s a huge sum of money and it exceeds the measures currently to address this problem.”
BAPEN, led by Dr Stroud, established the Malnutrition Universal Screening Tool (MUST) to ensure that those suffering from malnutrition or other nutritional problems are identified and managed. The idea of the screening tool was to improve nutritional care by detecting malnutrition in hospital, general practice and residential care settings.
All patients in hospital must receive the nutritional care appropriate to their needs, Dr Stroud said.
“Use food first, if it can be eaten and utilised, but if this is not appropriate, use nutritional supplements.”
What is vital is that all nutritional care and treatment started in hospital is continued when the patient is discharged back home under the care of their GP and community services, or to another care setting.
Evidence for supplements
It is a misconception that nutritional supplements stop people eating food, Dr Stroud said. “I think as a general rule, nutritional supplements should only be used for short periods to assist patients with a current illness, or residents that have some sort of illness. It brings them back to eating normal food, but it should be good quality. I don’t see that there are many situations in which residents or patients in any setting should be using supplements long term.” However, for certain patients with intestinal disorders, oral nutritional supplements are ‘a lifeline’, he added.
“There are lots of situations in which elderly patients in care homes, for example, might lose their appetite with a bout of flu or short period of hospitalisation. If you don’t supplement in those circumstances, they can easily lose weight and take a step down in their vulnerability; they catch a cold and end up sick or hospitalised again,” Dr Stroud said.
Often, the hospital stay is too short to reverse malnutrition because the patient’s appetite is suppressed. “It’s about understanding who to target with nutritional supplements.”
Dr Stroud estimates that around 5-10 per cent of patients in residential homes need to take nutritional supplements and almost 30 per cent of patients in hospital settings. Nutritional support should improve general health status by increasing immunity, wound healing, mobility and mental wellbeing. He highlighted studies showing the functional improvements in hospital and community patients taking oral nutritional supplements (ONS) and enteral nutritional feeds (ENF).
The studies showed that supplements improved respiratory function and increased walking distance in COPD patients. The nutritional supplements also brought a health benefit to elderly patients by improving immune function and daily mobility.
For HIV/AIDS patients, supplements improved cognitive function and for patients with liver disease, they improved liver function. Following surgery, patients who took nutritional supplements had greater wound healing and suffered from less fatigue. These patients also lost less muscle strength.
Dr Stroud highlighted research on the use of ONS and tube feeds. A randomised controlled trial of sip-feed supplements, about two per day, in 501 elderly patients showed that the group taking an ONS also ate more hospital food. Mortality in the ONS group was 8.6 per cent, compared to 18.6 per cent in the controlled group (Clinical Nutrition, 1990).
A Southampton systematic review looked at 287 trials on patients in the hospital and community setting. In total, 11,720 patients participated (Stratton et al, 2003).
The proportion of patients with complications was significantly reduced among patients taking a nutritional supplement. Patients taking ONS or ETF spent a shorter period in hospital than the control group and the nutritional aid reduced mortality rates.
Recommendations
Dr Stroud said that doctors should make certain the ONS used contains a balance of protein, energy, fibre, electrolytes, vitamins and minerals. It is important to stop the ONS when the patient is established on oral intake from normal food.
Although it is tempting to target nutritional prescribing costs, because costs have risen substantially in recent years, it would be the wrong measure and detrimental to some individuals – eventually adding to health costs, he added. Proper nutritional care will reduce costs from inappropriate ONS use, but ‘it will also identify more individuals who would benefit from them’, Dr Stroud said.
Healthcare costs of malnutrition are mainly from excess hospital spells, GP consultations and longer-term care needs of the malnourished, so a net increase in ONS, ETF and PN use is more than offset by savings, since current
costs of all these modalities amounts to only 2 per cent of
malnutrition-related costs.
Dr Stroud concluded that the nutritional budgets in care homes, mental health institutions, hospitals and schools are easy targets in recessionary times, but ‘this shouldn’t be cut; it should be something we improve’.