Nutrition and fluid balance must be taken seriously

Dear Sir,
we read with interest the paper by Leach and colleagues which was recently published in the Analysis section of the British Medical Journal (1).

The article neatly highlights that, although delivery of adequate fluid and nutrition should be a clear responsibility of all healthcare professionals, access to appropriate nutrition and hydration is still largely unmet in all types of healthcare facility in the UK. This is amazing, not only under the ethical perspective, but also when one considers the dramatic impact that malnutrition and dehydration have on outcome and healthcare costs (1).

Interestingly, the recent perspective by Krumholz in the New England Journal of Medicine, focusing on the post-hospital syndrome (2), pointed to the same direction: most of the hospital-discharged patients have heightened risks of several complications, in turn leading to hospital-readmissions, many of which have little in common with the initial diagnosis. In particular, a crucial role in determining impairment of wound healing, increased infection rates, decreased respiratory, cardiac and cognitive function seems to be played by malnutrition (2-4). Thus, malnutrition represents a common, albeit insidious comorbidity which is likely to determine the largest increase of hospitalization costs (5). Lim at al recently showed that average cost of hospitalization is 24% higher for malnourished patients and that the risk of readmissions within 15 days is increased by 60% for malnourished patients when compared to well-nourished patients (4).

Malnutrition recognizes a complex and multifactorial pathophysiology, in which insufficient food intake, altered metabolism and, in some cases, increased basal energy expenditure all play a relevant role. Anorexia, defined as the reduced desire to eat, is highly prevalent in acute and chronic diseases, causing reduced energy and protein-intake, thus significantly contributing to the clinical picture of malnutrition (6). A recent analysis of the nutritionDay® (an international and annual survey on hospital malnutrition’s prevalence and clinical impact) database, has demonstrated that anorexia is a risk factor for mortality in hospitalized patients (7). Moreover, anorexia and malnutrition are independently associated with in-hospital mortality and are strongly related to readmission rates within 90-days of discharge (8).

Quite surprisingly, as both Dr Leach and Dr Krumholz correctly point out in their articles, nutritional issues during hospital stay receive very limited attention. The question then arises: why is such a highly prevalent comorbidity disregarded and neglected in clinical practice, despite its detrimental effects on outcomes and healthcare costs? One possible answer is that malnutrition, unlike hypertension, diabetes, dyslipidemia, etc, is not yet recognized as a clinical risk factor, likely as a consequence of the limited and inconsistent teaching of nutritional matters in medical schools worldwide. Another hypothesis is that malnutrition, given the pathophysiological complexity, the phenotypical variability and the lack of simple operational diagnostic criteria, is often not recognized at all both in hospitals and in the community.

Promoting good nutrition and hydration and addressing nutritional deficiencies are among the strategies proposed to mitigate post-hospital syndrome and its accompanying risks (1,2). This represents a challenge for health professionals and healthcare systems which will be won if awareness of malnutrition and its early recognition and treatment will become an integral part of good clinical practice.

Unmasking the hidden killer represented by malnutrition will translate not only in a reduction of healthcare costs, but, above all, in an improvement of patients’ vulnerability and quality of life.

References
1. Leach RM, Brotherton A, Stroud M, Thompson R. Nutrition and fluid balance must be taken seriously. BMJ. 2013;346:f801. doi: 10.1136/bmj.f801.
2. Krumholz HM. Post-Hospital Syndrome – An Acquired, Transient Condition of Generalized Risk, N Engl J Med. 2013 Jan 10;368(2):100-2. doi: 10.1056/NEJMp1212324.
3. Lim SL, Ong KC, Chan YH, Loke WC, Ferguson M, Daniels L. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr 2012;31:345e50.
4. Spaccavento S, Del Prete M, Craca A, Fiore P. Influence of nutritional status on cognitive, functional and neuropsychiatric deficits in Alzheimer's disease. Arch Gerontol Geriatr. 2009;48(3):356-60.
5. Nikkel LE, Fox EJ, Black KP, Davis C, Andersen L, Hollenbeak CS. Impact of comorbidities on hospitalization costs following hip fracture. J Bone Joint Surg Am 2012;94:9e17.
6. Molfino A, Laviano A, Rossi Fanelli F. Contribution of anorexia to tissue wasting in cachexia.
Curr Opin Support Palliat Care. 2010;4:249-53.
7. Hiesmayr M, Schindler K, Pernicka E, Schuh C, Schoeniger-Hekele A, Bauer P, et al, NutritionDay Audit Team. Decreased food intake is a risk factor for mortality in hospitalised patients: the NutritionDay survey 2006. Clin Nutr 2009;28:484e91.
8. Agarwal E, Ferguson M, Banks M, Batterham M, Bauer J, Capra S, Isenring E. Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: Results from the Nutrition Care Day Survey 2010. Clin Nutr. 2012 Dec 5. pii: S0261-5614(12)00269-5. doi: 10.1016/j.clnu.2012.11.021