Malnutrition has been shown to be prevalent in pediatric and adult patients with a variety of different diseases and conditions. Patient populations that may be at risk for malnutrition include pediatric;1 patients with cancer;2 patients with gastroenterologic conditions;3 geriatric patients;4,5 patients with renal insufficiency;6 patients with human immunodeficiency virus/acquired immune deficiency syndrome;7 patients with chronic liver disease;8 patients with chronic obstructive pulmonary disease (COPD);9 or patients with congestive heart failure (CHF);10 and surgical patients.11
Further details of the prevalence of malnutrition in some of these patient populations are provided in the following sections:
Malnutrition is common in preterm infants, especially in critically ill preterm neonates in the neonatal intensive care unit (NICU) who may have increased metabolic demands.12 This nutritional deficit may result in extrauterine growth restriction (EUGR).13 In preterm infants, the immature gastrointestinal (GI) system may limit the route of nutrition delivery and these infants commonly survive on parenteral nutrition.14 Other reasons for pediatric malnutrition are congenital anomalies of the GI tract, including obstructive anomalies, such as Hirschsprung disease and atresias.15 Necrotizing enterocolitis (NEC) is a disease of the neonatal bowel, which manifests in bowel inflammation and is closely related to prematurity. NEC is also a cause for short bowel syndrome.16 Other causes of short bowel syndrome include abdominal wall defects, jejunal ileal atresia and mid gut volvulus.16
A retrospective review of an administrative database of more than 24,000 preterm neonates from 124 NICUs showed that 28%, 34%, and 16% of patients experienced EUGR for weight, length, and head circumference, respectively.13 Low birth weight and immature gestational age were considered the most important factors associated with the occurrence of EUGR.13 Length of hospital stay has been shown to adversely affect the nutritional status of preterm infants. 17 A prospective, observational study by Hulst et al, of 293 children, including 104 preterm infants (gestational age <37 weeks; post-conceptual age ≤ 40 weeks), showed a decline in nutritional status during their stay, with the proportion of preterm infants classified as acutely malnourished significantly (P<0.001) increasing from 14% to 32% from admission to discharge.17 Six months after discharge, 15% of the preterm infants were still acutely malnourished.17
A review of literature documenting the prevalence of acute malnutrition in hospitalized children with mixed diagnoses in the last 10 years reported that the prevalence of acute malnutrition was 6.1% in Germany, 11–21% in France, 8–14% in the United Kingdom (UK), 6.9% in Brazil and 7.1% in the United States of America (USA) (Table 1).18 This review also noted that two studies in Turkey reported a high prevalence of malnutrition in pediatric patients (27.7% and 31.8%).18 The authors of this review concluded that the prevalence of acute malnutrition is substantial, especially in children with underlying disease such as cardiac disease (prevalence of chronic malnutrition 24–44%) and renal disease (63–64%).18
Some causes of malnutrition in pediatric patients include cancer,19 intractable diarrhea, Crohn's disease and chronic intestinal pseudo-obstruction (CIPO), which is characterized by loss of gut motility.20,21 Children with inflammatory bowel disease (IBD) commonly have issues with malnutrition and micronutrient defiencies, which can lead to growth failure, delayed onset of puberty and delayed skeletal maturation.21
|Hendricks et al22||USA||0–18 years||268||7.1||WFH<80%|
|Pawellek et al23||Germany||All ages||475||6.1||WFH<80%|
|Rocha et al24||Brazil||<5 years||186||6.9||WFH<-2 SD|
|Marteletti et al25||France||2 months–16 years||280||11||WFH<-2 SD|
|Dogan et al26||Turkey||1 month–23 years||528||27.7||WFH<-2 SD|
|Ozturk et al27||Turkey||2–6 years||170||31.8||% ideal BW/H <80%|
|Hankard et al28||France||>6 months||58||21||BMI<-2 SD|
|Hendrikse et al29||UK||7 months–16 years||226||8.0||WFH<80%|
|Moy et al29||UK||3 months–18 years||255||14||WFH<-2 SD|
BMI:body mass index; BW/H: bodyweight for height; WFH: weight for height
*Prevalence(%) derived from original studies using equivalent criteria.
Reproduced with permission from Joosten KF, Hulst JM. Prevalence of malnutrition in pediatric hospital patients. Curr Opin Pediatr 2008;20:590–596.
The primary observation from a prospective, observational study by Hulst et al was that critically ill children admitted to ICU were in a poorer nutritional status (energy and protein deficits) than the general population.17 In addition, the prevalence of malnutrition in term infants (0–30 days; n=96) increased during the ICU stay.17 The percentage of term neonates with acute malnutrition increased significantly (P<0.001), from 9% at admission to 23% at discharge (Figure 1).17 Six months after discharge, 12% of children were classified as acutely malnourished, which was similar to the proportion at admission.17 The proportion of children (median [range] age 1.4 years [31 days to 17 years]; n=93) with acute (22%) or chronic (11%) malnutrition upon discharge did not differ from those at admission.17
Two studies have shown that the prevalence of malnutrition in hospitalized pediatric patients is high in acute and chronically ill infants and young children (2–5 years) (Table 2).
|Author||Type of study||Country||Patient setting||Prevalence of malnutrition|
|Hendricks 199522||Cross-sectional survey||USA||Inpatients in a tertiary care facility||Children <2 years of age and with chronic medical conditions had the highest prevalence of protein energy malnutrition Children <2 years of age (N=68): 30.9% severe malnutrition 14.7% mild malnutrition*|
|Pawellek 200723||Consecutive admission of inpatients to two general pediatric wards or one pediatric surgery ward||Germany||Tertiary care children's hospital||Infants (<1 year of age; N=28 assessed) and young children (2–5 years; N=164 assessed) had the highest prevalence of malnutrition Infants: 14.3% mild malnutrition; 7.1% moderate or severe malnutrition at admission* Children: 23.8% mild malnutrition; 4.3% moderate malnutrition|
|*Based on the Waterlow criteria the degree of acute protein-energy malnutrition (PEM) (weight for height) was categorized as normal (>90% of the median), mild (81–90% of the median), moderate (70–80% of the median), or severe (<70% of the median)31|
Malnutrition has been shown to be a major clinical problem, occurring in 20–50% of hospitalized adult patients worldwide, depending on the patient population and the criteria used to diagnose malnutrition (Tables 3 and 4).
In a literature review that focused on prognostic implications of disease-related malnutrition, Norman et al summarized the global prevalence of malnutrition reported in studies across different patient groups.32 On average, 41.7% of patients worldwide and 31.4% of patients hospitalized in the USA and Europe were considered malnourished. This review also demonstrated that moderate and severe malnutrition led to an increased length of hospital stay compared with patients with normal nutrition.
|Edington et al33||UK||Elective and emergency medicine||850||20|
|Kondrup et al34||Denmark||Multidisciplinary||740||23|
|Pirlich et al35||Germany||Multidisciplinary||1886||27|
|Wyszynski et al36||Argentina||Multidisciplinary||1000||47|
|Waitzberg et al37||Brazil||Internal medicine||4000||48|
|Correia and Campos38||Latin America||Multidisciplinary||9348||50|
|*Various nutrition screening/assessment methods were used|
|Author||Location||Specialty||Prevalence (%) (n/N)|
|Veterans Affairs study group39||Multiple Veteran's Affairs medical centers||Abdominal/thoracic surgery||39
|Coats et al40||Birmingham, AL||General medicine||38
|Giner et al41||Syracuse, NY||Intensive care||43
|Robinson et al42||Boston, MA||General medicine||33
|*Various nutrition screening/assessment methods were used|
A multicenter, cross-sectional, epidemiologic study assessed the nutrition status and prevalance of malnutrition in 25 hospitals across 12 Brazilian states over 6 months.37 This study assessed the nutritional status of 4,000 hospitalized patients, and determined the prevalence of malnutritrion using Subjective Global Assessment (SGA). Malnutrition was present in 48.1% of patients, and 12.5% were severely malnourished. Malnutrition was associated with primary diagnosis at admission, age >60 years, and the presence of cancer or infection. As the length of hospital stay increased, so did the rate of malnutrition (Figure 2). A hospital stay of ≥15 days conferred a 3-fold greater chance of being malnourished. The authors concluded that awareness of nutritional status was low, as evidenced by any information on nutrition status being present in fewer than 18.8% of patients' records. As a result, nutrition therapy was underprescribed.
Figure reproduced from Nutrition, 17, Waitzberg DL, Caiaffa WT, Correia MI. Hospital malnutrition: the Brazilian national survey (IBRANUTRI): a study of 4000 patients. pp. 573–580., Copyright (2001) with permission from Elsevier.
The incidence of malnutrition varies with patient type and severity of condition, with elderly patients being particularly vulnerable. Therefore, it has been recommended that protocols and methods should be developed to routinely assess the nutritional status of elderly patients.43
A German hospital malnutrition study was conducted in 1,886 consecutively admitted patients in 13 hospitals. Of these patients, 27.4% were malnourished, based on SGA; 17.6% were classified as moderately malnourished, and 9.8% were classified as severely malnourished. Forty-three percent of patients aged ≥70 years were malnourished, with 16.7% classified as severely malnourished. In comparison, only 7.8% of patients aged <30 years were classified as malnourished, and none were classified as severely malnourished. The highest prevalence of malnutrition was found in geriatric departments, followed by oncology and gastroenterology departments. Patients classified as malnourished had a hospital stay that was 4.6 days longer, on average, then that of patients who were not malnourished.35
A study looking at the prevalence of malnutrition in 623 hospitalized elderly patients concluded that elderly patients with dementia had a higher frequency of malnutrition than patients with normal cognition (P<0.0001; odds ratio [OR]=3.2, 95% confidence interval [CI]=1.6–6.2).44 This study also found that the frequency of malnutrition in patients with mild cognitive impairment was significantly higher than in patients with normal cognition (P<0.0001; OR=4.7, 95% CI=2.5–9.0), and was not significantly different from that in patients with dementia (P=0.087; OR 1.1, 95% CI=0.5–2.4).
Weight loss has been shown to contribute to mortality in cancer patients. Often, weight loss is one of the first symptoms of cancer.45 Approximately 15% of patients have experienced severe involuntary weight loss (>10% of usual body weight over the previous 6 months) by the time of diagnosis.45 Andreyev et al performed a retrospective review of a database of patients with GI cancers. In patients with esophageal, gastric, and pancreatic cancers approximately 70% had weight loss at presentation for chemotherapy. In patients with colorectal cancers, approximately one third had weight loss (Figure 3).46
Scientists have shown that malnutrition and skeletal muscle loss in patients with cancer are not only driven by insufficient nutrient intake, but also by metabolic changes associated with the cancer.
Insufficient food intake can have physical and psychological causes.47 Poor appetite, swallowing problems, and the side effects of drugs are only some of the problems that lead to declining food intake. Patients with taste changes, nausea, or neurologic conditions may be especially affected, because they are not always able to consume adequate nutrition.
One reason for tumor-associated metabolic changes is that tumor cells stimulate catabolism and cytokine production, which eventually leads to loss of appetite and may facilitate tumor progression.45
Cancer cachexia syndrome (CCS), a syndrome of severe malnutrition often seen in patients with advanced malignancies but can also occur in early stages of tumor growth, is observed in approximately 50% of patients with cancer.2 Causes of CCS include anorexia, alterations in energy metabolism, side effects of treatment, mechanical factors affecting the GI tract due to the tumor and changes in the host cytokine and hormonal milieu.2
The prevalence of weight loss depends on cancer type, and is especially high for gastric and pancreatic cancer.48 In a prospective study of 74 patients with stage II or III esophageal cancer, 43 (58%) lost more than 10% of their usual weight within 6 months prior to admission (P<0.001).49
Of 111 patients aged 64.4 ± 9.3 years, who had pancreatic cancer and had undergone an abdominal computed tomography (CT) scan within 60 days of initial assessment, 56% had a low muscle mass index at this first CT scan.50 Follow-up CTs in 44 patients showed an increase in sarcopenia from 45.5% (20 patients) to 61.4% (27 patients). Patients who were overweight/obese and sarcopenic (18/111; 16.2%) had a median survival of 55 days, compared with 148 days for the rest of the cohort without overweight/obese sarcopenia.
Malnutrition is also common in CHF patients, with cardiac cachexia syndrome (CCS) occurring in a subset of this population. One of the first descriptions of CCS was published by Pittman and Cohen in 1964.51 The prognostic importance of weight loss in CHF was reported by Anker et al, who recommended that weight loss of more than 6% should be used to define the presence of CCS in patients with CHF.52
The prevalence of CCS, defined as weight loss of ≥7.5% during 6 months at least, was estimated to be 16% in a study of 171 patients with CHF (New York Heart Association [NYHA] classes II–IV).53 In a study of 62 patients with CHF (NYHA classes II–III), evidence of skeletal muscle atrophy was observed in 68% of patients.54 The authors reported that the results of dietary histories suggested that decreased caloric and protein intake were major contributors to muscle atrophy.
The pathophysiology of CCS remains unclear. Neuroendocrine and immunologic disturbances are thought to underlie an altered balance between anabolism and catabolism in affected patients (Table 5). Pre-albumin has been proposed as a laboratory marker of CCS.55
|Biochemical changes associated with CCS|
|Increased plasma catecholamines56|
|Increased plasma cortisol56|
|Increased plasma aldosterone56|
|Increased plasma renin56|
|Steroid and growth hormone resistance57,58|
|Increased plasma adiponectin61|
Altered intestinal function is now considered by some authors to play a key role in the pathogenesis of CCS.62,63 Decreased cardiac function may reduce bowel perfusion and, therefore, impair the function of the gut barrier. The resulting 'leakiness' of the bowel wall may lead to translocation of bacteria and/or endotoxins, which, in turn, may sustain inflammatory cytokine activation and worsen nutritional status.64 Decreased cardiac function may lead to bowel wall edema and, thus, malabsorption.65 Fat malabsorption may also be important in CCS.66
Malnutrition is highly prevalent in patients with alcoholic and non-alcoholic cirrhosis, and has been shown to adversely affect outcomes in these populations. Poor dietary intake, malabsorption, increased intestinal protein losses, low protein synthesis, disturbances in substrate utilization, and hypermetabolism are among the mechanisms thought to contribute to such malnutrition, but these mechanisms remain poorly understood.67
In a prospective, single-center, observational study in patients with alcoholic (n=77) or virus-related (n=43) cirrhosis, severe energy malnutrition (defined as triceps skin-fold thickness [TSF] and/or midarm muscle circumference [MAMC] under the 5th percentile of the standard range) was noted in 34% of patients.68 Protein malnutrition (defined by low values of albumin, transthyretin, transferrin, and retinol-binding protein) was present in 81% of patients.
A further prospective, single-center, observational study of 212 hospitalized patients with liver cirrhosis, followed for 2 years, found that 34% of patients had MAMC and/or TSF below the 5th percentile of the reference population, and, therefore, were defined as severely malnourished.8 The prevalence of severe malnutrition was also shown to be higher in patients with more severe liver impairment (Child-Pugh class C; 46%) than in those patients with less severe liver impairment (Child-Pugh class A; 13% [P<0.001] or Child-Pugh class B; 35% [P<0.01]). Moreover, the degree of malnutrition was related to the risk of death (Figure 4).
P<0.001 at 6, 12, and 24 months for comparison of patients with severe and moderate malnutrition (groups 1 and 2, respectively) versus those who had normal nutrition or were over-nourished (groups 3 and 4, respectively). Patients with transplants were screened at the time of transplantation.
In a third prospective, single-center, observational study, which included 396 hospitalized patients with cirrhosis, 53% and 38%, respectively, were found to have MAMC and TSF below the 5th percentile of the reference population.69 Decrease in dietary intake correlated with increasing severity of liver failure. In total, 48% of Child-Pugh class A patients, 52% of Child-Pugh class B patients, and 80% of Child-Pugh class C patients at admission had low caloric intakes (<30 kcal/kg body weight; P<0.001).
It is estimated that malnutrition is present in 25–40% of patients with advanced COPD.9 Clinically relevant weight loss (5% within 3 months, or 10% within 6 months) is present in 25–40% of all patients with severely impaired lung function (forced expiratory volume <50%).9 A number of factors are believed to contribute to the cachexia found in patients with COPD; however, loss of appetite and decreased food intake are particularly important.9
The prevalence and prognostic importance of weight change in unselected individuals with COPD was examined in the prospective, observational Copenhagen City Heart Study (N=14,223), in which participants attended two examinations 5 years apart, and were then followed for 14 years to evaluate COPD-related and all-cause mortality.70 The percentage of subjects whose body mass index (BMI) decreased by >1 unit (~3.8 kg) between visits increased with decreasing lung function, and reached 35% in females and 27% in males with severe COPD. After adjusting for age, smoking habits, baseline BMI, and lung function, weight loss was associated with higher mortality in individuals with COPD than in those without COPD (relative risk of weight loss of >3 BMI units = 1.71 [95% CI 1.32–2.23]).
The French National Cooperative Study, a prospective, multicenter, observational study, examined the nutritional status of 7,123 patients requiring hemodialysis - approximately one-third of the French hemodialysis population.71 This study revealed life-threatening malnutrition in 20–36% of the study population (below high-risk thresholds for albumin [35 g/L] and pre-albumin [300 mg/L]). The authors concluded that the major contributors to nutritional status were protein intake and dialysis efficiency.
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EUMP/MG17/15-0009 Aug 2015