Prevalence of malnutrition in healthcare settings

In 1994 a landmark paper published by McWhirter et al. in the British Medical Journal raised concerns that 40 % (200/500) of patients admitted to an acute UK hospital were malnourished⁽ Reference McWhirter and Pennington ^{8 )}. A further concern highlighted in this study was that patients continued to lose weight during their hospital stay (mean weight loss of 5·4 %). Since the publication of this seminal paper, there have been numerous other studies performed in the UK, demonstrating a prevalence of malnutrition in UK hospitals ranging between 11 and 45 %⁽ Reference Ray, Laur and Golubic ^{9 )}. Although considerable heterogeneity exists between these published studies, findings collectively suggest that malnutrition in hospitals remains highly prevalent in the UK today. These findings are supported by a recent publication from the British Association for Parenteral and Enteral Nutrition using the Malnutrition Universal Screening Tool (discussed later)⁽ Reference Elia ^{10 )}. This report estimates adult malnutrition to affect: 30 % on admission to hospitals, 34 % in hospital wards, 35 % admitted to care homes, 35 % already resident in care homes, 18 % admitted to mental health units, >15 % attending hospital outpatient clinics and 10 % of patients visiting general practitioners⁽ Reference Elia ^{10 )}.

Problems with malnutrition in healthcare settings are not confined to the UK. In a multicentre study evaluating 21 007 patients from 325 hospitals across Europe and Israel, 27 % of patients were subjectively identified as being at nutritional risk⁽ Reference Schindler, Pernicka and Laviano ^{11 )}. In Latin America, a recent systematic review of sixty-six studies encompassing 29 474 patients from twelve countries, demonstrated a prevalence of disease-related malnutrition on hospital admission between 40 and 60 %. Similar findings have been reported from other industrialised nations across the globe⁽ Reference Gout, Barker and Crowe ^{12 –} Reference Rahman, Wu and Bricknell ^{15 )}.

Improving nutritional care through screening and assessment

Over recent decades several publications from differing professional bodies and patient organisations have raised concerns about the detection of malnutrition⁽ Reference Kopelman and Lennard-Jones ^{16 – 19 )}. Consequently, an array of screening and assessment tools has been devised to help assess malnutrition and determine malnutrition risk. Nutritional screening refers to a rapid and simple means of predicting malnutrition risk, whereas nutritional assessments determine whether malnutrition is actually present⁽ Reference Barker, Gout and Crowe ^{20 )}. The benefits of screening tools are that they can be used by an array of trained healthcare professionals, whereas nutritional assessments require greater expertise, and are most frequently performed by trained dietitians.

The Malnutrition Universal Screening Tool is the nutrition screening tool most frequently used in the UK, incorporating present BMI, unintentional weight loss and the presence of any acute disease effect that could compromise nutritional intake for >5 d⁽ Reference Elia and Russell ^{21 )}. It has been shown to have high predictive validity in both the community and hospital environments (length of hospital stay, mortality in elderly wards, discharge destination in orthopaedic patients)⁽ Reference Elia and Russell ^{21 –} Reference Poulia, Klek and Doundoulakis ^{23 )}. Another screening tool adopted is the Nutritional Risk Screening 2002, which includes four questions about: BMI (if it is <20·5), presence of weight loss in the past 3 months, presence of low dietary intake in the past week and the severity of disease⁽ Reference Kondrup, Rasmussen and Hamberg ^{24 )}. This Nutritional Risk Screening 2002 was advocated in the 2002 European Society for Clinical Nutrition and Metabolism guidelines, however its performance against Malnutrition Universal Screening Tool was recently found to be inferior in the context of the latest European Society for Clinical Nutrition and Metabolism consensus definition for malnutrition⁽ Reference Poulia, Klek and Doundoulakis ^{23 ,} Reference Kondrup, Allison and Elia ^{25 )}.

Other tools used in clinical practice include the Mini Nutrition Assessment, the Subjective Global Assessment and the Short Nutrition Assessment Questionnaire⁽ Reference Guigoz ^{26 –} Reference Kruizenga, Seidell and de Vet ^{28 )}. Despite the benefits of nutritional screening in healthcare settings and the requirement to do so in certain countries (e.g. UK, USA), the use of these tools remains highly variable, with no one tool being universally adopted in all settings⁽ Reference Raslan, Gonzalez and Dias ^{29 ,} Reference van Bokhorst-de van der Schueren, Guaitoli and Jansma ^{30 )}.

Economic costs of malnutrition

Although the physical and psychological manifestations of malnutrition have been extensively investigated, until recently there has been limited work evaluating the economic costs of malnutrition. This paucity of work highlights the difficulties in attributing monetary value to certain consequences of malnutrition that may be influenced by disease status, socioeconomic status, life expectancy, alongside the perspective from which the economic analysis is being undertaken (e.g. patient, healthcare professional or general public)⁽ Reference Elia ^{31 )}. In European countries the annual costs of disease related malnutrition have been calculated in The Netherlands (2011), Germany (2006), UK (2012) and Ireland (2007) equating to € 1·9 billion, € 9 billion, € 19·6 billion and € 1·5 billion, respectively⁽ Reference Freijer, Tan and Koopmanschap ^{32 ,} Reference Elia ^{33 )}. As a cost per adult (>18 years) capita for these four individual nations, costs translate to € 135, € 134, € 370, € 500, respectively. These variations in outcomes highlight the differences in methodology used to calculate costs, with the UK data considering all healthcare costs, e.g. total general practitioner visits and costs for providing domiciliary and home care, compared with the findings from the Netherlands that only assesses additional costs due to disease related malnutrition⁽ Reference Freijer, Tan and Koopmanschap ^{32 )}. Improving the understanding of direct healthcare costs of malnutrition (e.g. cost of travelling expenses to patients and carers to receive nutrition support), and of the indirect healthcare costs such as reduction in work productivity, would help enhance costing calculations.

The benefits of health economics data in this field can be demonstrated when considering the effectiveness and efficacy of interventions for treating malnutrition. This has recently been the subject of a Cochrane systematic review, supporting the use of nutritional therapy in reducing healthcare costs. This work also highlights the need for future work to investigate the impact nutritional therapies have on malnutrition and on hospital readmission rates⁽ Reference Muscaritoli, Krznaric and Barazzoni ^{34 )}.

Nutrition support

Nutrition support involves the provision of nutrition beyond that provided by normal food intake using oral supplementation, enteral tube feeding and parenteral nutrition^{( 19 )}. The goals of nutrition support are to ensure attainment of an individual's nutritional requirements. Oral nutrition using special diets and supplements is usually considered the first line therapy in managing malnutrition, however certain individuals may require enteral or parenteral nutrition when oral intake is reduced or when swallowing is unsafe⁽ Reference Kurien, Penny and Sanders ^{35 )}. Of these modalities, enteral nutrition is usually preferred in the context of a normally functioning gastrointestinal tract as it is physiological, cheaper and may help maintain gut barrier function⁽ Reference Buchman, Moukarzel and Bhuta ^{36 ,} Reference Braunschweig, Levy and Sheean ^{37 )}.

Most patients requiring nutrition support therapy have treatment for less than 1 month⁽ Reference Pearce and Duncan ^{38 )}. When short-term enteral feeding is considered, nasogastric and orogastric tubes are most frequently used, reflecting their ease of insertion and removal (Fig. 1). Tubes range in length and diameter and can be inserted either at the bedside, at endoscopy or using radiological guidance. When nutritional intake is likely to be inadequate for more than 4–6 weeks then enteral feeding using a gastrostomy is most frequently considered (Fig. 2)⁽ Reference Kurien, McAlindon and Westaby ^{39 )}. This intervention for providing nutritional support is discussed in further detail later.

Fig. 1. (Colour online) Methods of enteral feeding.

Fig. 2. (Colour online) A gastrostomy feeding tube.

History of gastrostomies and techniques of insertion

A gastrostomy describes a feeding tube placed directly into the stomach via a small incision through the abdominal wall (Fig. 2). It can provide long term enteral nutrition to patients who have functionally normal gastrointestinal tracts but who cannot meet their nutritional requirements due to an inadequate oral intake⁽ Reference Kurien, McAlindon and Westaby ^{39 )}. Infrequently, they may also be used for decompressing the stomach or proximal small bowel following outflow obstruction or volvulus.

The concept of a gastrostomy was first proposed by Egeberg, a Norwegian army surgeon in 1837, however it was only in 1876 when Verneuil used a silver wire to oppose visceral and parietal surfaces that success was achieved in inserting a surgical gastrostomy⁽ Reference Cunha ^{40 )}. Post-procedural peritonitis was the most frequent limitation to previous attempts at surgical insertion, with death ensuing in individuals who developed this complication. Stamm modified Verneuil's surgical technique in 1894, prior to modifications being developed by Dragstedt, Janeway and Witze in the 20th century⁽ Reference Minard ^{41 )}.

In 1979, Michael Gauderer and Jeffrey Ponsky revolutionised gastrostomy practice by pioneering an endoscopic method of insertion in Clevleand, Ohio⁽ Reference Gauderer, Ponsky and Izant ^{42 )}. The two paediatricians performed the very first percutaneous endoscopic gastrostomy (PEG) in a 6-month old child, using a 16 French DePezzar (mushroom tipped) catheter, which they replicated again in a further five paediatric cases⁽ Reference Ponsky ^{43 )}. Ponsky then utilised this technique in a cohort of adult patients with dysphagic strokes, which heightened interest in this novel endoscopic technique⁽ Reference Ponsky ^{43 )}. The ‘pull technique’ that they pioneered is presently one of the three endoscopic methods frequently used today in clinical practice. When compared with previously used surgical methods, endoscopic insertion was favourable, as it was minimally invasive and incurred lower morbidity and mortality.

Two years later in 1981, Preshaw in Canada used fluoroscopic guidance to insert the first percutaneous radiological gastrostomy⁽ Reference Preshaw ^{44 )}. Like endoscopic methods, modifications of the original radiological technique have occurred since the original method was conceived. However, despite these advances endoscopic techniques remain the most popular methods of insertion internationally, with percutaneous radiological gastrostomy insertion most frequently reserved for high-risk patients, oropharyngeal malignancy and when endoscopic passage is technically difficult⁽ Reference Galaski, Peng and Ellis ^{45 ,} Reference Ozmen and Akhan ^{46 )}.

Indications for gastrostomy

Since the introduction of endoscopic and radiological insertion techniques for gastrostomy, there has been increasing demand for this intervention, for an increasing number of clinical indications. A broad list of indications for which patients are presently being referred for gastrostomy is given in Table 1. Despite being widely performed the evidence base to support gastrostomy feeding in certain patient groups is lacking. This is reflected in the National Confidential Enquiry into Patient Outcome and Death report, which reviewed mortality outcomes of post-percutaneous endoscopic gastrostomy insertion between April 2002 and March 2003, identifying a 30-d mortality rate in a cohort of 16 648 patients of 6 %^{( 47 )}. Subgroup analysis alarmingly showed that 43 % died within 1 week of undergoing PEG insertion, of whom in 19 % the intervention was felt to have been futile. Interestingly, the National Confidential Enquiry into Patient Outcome and Death data identified a high prevalence of acute chest infections (40 %) in those undergoing PEG placement, which could have influenced these mortality outcomes. The present evidence regarding gastrostomy feeding in certain patient subgroups is discussed later.

Table 1. Conditions where gastrostomy feeding is considered

Gastrostomy feeding and nutritional outcomes

Optimising referral for gastrostomy insertion and aftercare

There has been increasing interest in improving patient selection for gastrostomy insertion⁽ Reference Heaney and Tham ^{76 –} Reference Nair, Hertan and Pitchumoni ^{78 )}. One method used internationally to optimise referral practice is to employ institutional guidelines that use a standardised referral protocol. Use of a multidisciplinary team in assessment of patients and dissemination of evidence can allow both carers and healthcare professionals to make an informed decision. This approach has been shown (in observational studies) to improve the selection of patients referred for gastrostomy⁽ Reference Sanders, Carter and D'Silva ^{79 –} Reference Monteleoni and Clark ^{81 )}.

When considering whether insertion of a gastrostomy tube is appropriate, the question that must be asked is whether gastrostomy feeding would maintain or improve a patient's quality of life. This question must be answered in the context of the underlying diagnosis and prognosis, considering moral and ethical issues, as well as respecting the patient's wishes. Guidelines exist to aid clinicians in making decisions on gastrostomy feeding; however the decision to insert a feeding tube should always be made on an individual basis^{( 19 ,} Reference Rabeneck, McCullough and Wray ^{82 )}.

Another factor that may be influencing outcomes following gastrostomy insertion is variations in the organisation of aftercare services. In the UK study, looking at provision of services for gastrostomy, only 64 % of units had a dedicated aftercare service⁽ Reference Kurien, Westaby and Romaya ^{83 )}. The benefits of dedicated home enteral feed teams have been shown to reduce costs and morbidity associated with gastrostomy feeding⁽ Reference Kurien, White and Simpson ^{84 ,} Reference Dinenage, Gower and Van Wyk ^{85 )}. Given that most complications of gastrostomy feeding occur following hospital discharge, effort should be made to improve the delivery of aftercare and procurement of these services for the benefit of patients.

Ethical and legal considerations of gastrostomy feeding

Gastrostomy feeding raises ethical and legal issues. Both the Royal College of Physicians and the General Medical Council in the UK have provided guidance on oral feeding and nutrition^{( 86 , 87 )}. Artificial feeding is considered a medical treatment in legal terms and requires valid consent prior to commencement. For consent to be valid the person giving consent must have the capacity to do so voluntarily after being given sufficient information to guide informed choice. When a patient has capacity their wish to consent to or refuse treatment should be upheld, even if that decision may lead to death. When a patient lacks capacity an independent mental capacity advocate should represent that individual. The multidisciplinary team caring for the patient is responsible for giving, withholding or withdrawing treatment, including artificial feeding and hydration and should consider any advance directives, the patient's prognosis and the likely benefits of gastrostomy feeding when making decisions. A limited trial of feeding may sometimes be used but strict criteria regarding what constitutes success should be determined prior to starting gastrostomy feeding⁽ Reference Stroud, Duncan and Nightingale ^{74 )}. Conflicts sometimes arise between health care professionals or between the professionals and those close to the patient. In such circumstances it may be necessary to seek legal advice or seek resolution through a local clinical ethics committee^{( 88 )}. Anecdotally, such conflicts appear to be rising with increased patient and family demands for intervention, which may in turn be influenced by emotion or by cultural beliefs.

The National Institute for Health and Care Excellence dementia guidelines highlight the importance of quality of life in advanced dementia and support the role of palliative care in these individuals from diagnosis until death. Best practice in these patients could be to encourage eating and drinking by mouth for as long as tolerated, utilising good feeding techniques, altering food consistencies and to promote good mouth care. Assisting hand feeding in this way has recently been shown to be of benefit in elderly patients, with volunteer assistance improving oral intake and enjoyment of meals⁽ Reference Gilbert, Appleton and Jerrim ^{89 )}. When disease progression is such that the patient no longer wants to eat or drink, then rather than inserting a gastrostomy tube, end of life care pathways might be considered. Views held by carers and medical staff may prevent progression to end of life care pathways. A questionnaire survey demonstrated that allied health care professionals were more likely than physicians to consider gastrostomy feeding when presented with patient scenarios relating to malnutrition⁽ Reference Watts, Cassel and Hickam ^{90 )}.