Malnutrition, not just Africa. It costs Europe 120 billion a year

"Following the publication of the reasoning behind the ruling that convicted the doctors who treated Stefano Cucchi during his hospital stay, the Pertini Hospital in Rome has reached a financial settlement with the family.."

A SAD AND DEPLORABLE CASE

According to the judges, this was not a case of “abandonment of an incapacitated person” but of “manslaughter”, linked to lack of skill, imprudence and negligence through the failure to provide a correct diagnosis and an adequate treatment plan, neither of which was particularly difficult in itself, and, finally, for failing to monitor the patient's deteriorating clinical course, thus not putting in place other measures (transfer to a more suitable facility) that could have saved the patient's life.

Beyond any assessment of the merits of the ruling, it is striking that it is —once again— the judiciary that highlights what we specialists already know and have been “preaching” for years: malnutrition (in Cucchi's case simplistically diagnosed as severe thinness) is an important factor in determining the patient's clinical outcome, that is, factors such as mortality but also length of hospital stay, complications, as well as the much-decried healthcare costs.
In 2010, a study published in the Journal of Clinical Nutrition estimated the cost of malnutrition at European level at 120 billion euros.

Although the occasion is a sad and deplorable one, it would be appropriate for the entire medical profession and —above all— the administrative leadership of healthcare facilities to acknowledge the existence of malnutrition (a lack of awareness) and to put in place the measures needed to diagnose and treat it. With the recent “spending review” the same mistakes were made once again, treating nutrition as a purely gastronomic, that is, hospitality matter, rather than as an important healthcare act.
Unfortunately, the decimation of Dietetics and Clinical Nutrition Units under way across the country (not cuts but reorganizations!) is certainly not an encouraging sign.

NOT ONLY IN AFRICA

Modern medicine has access to highly advanced technologies, genetic engineering, biological drugs and much more. Yet it is still possible to “starve to death”, especially in hospitals and nursing homes for the elderly. A phenomenon that to us wealthy Westerners seems typical of situations distant in time (concentration camps during World War II) or in space (African populations) is in fact present at our latitudes too and, as its characteristics are studied, it appears increasingly significant — so much so that, for some years now, first at European and then at global level, the scientific societies dealing with nutrition have been waging a battle against malnutrition in line with the European Council resolution on nutritional support in hospitals (2003), known as "Nutrition Day".

The literature on the effects of nutritional status on the natural history of disease is by now very extensive, and it is astonishing how, in the face of these data, the problem of malnutrition remains so little known and, even when suspected, is treated condescendingly as a mere gastronomic issue: it is no coincidence that in the recent spending review hospital catering was treated as a hospitality matter rather than a healthcare one, in stark contrast with the recent document approved at the State-Regions Conference on 16 December 2010, published in Official Gazette no. 37 of 15 February 2011, containing the National Guidelines for hospital and care-facility catering.

BUT ALSO IN EUROPE

And yet the prevalence of malnutrition in Europe ranges from 17 to 45% among hospitalized patients and between 50 and 85% among institutionalized patients. In Italy, the PIMAI study (Project Iatrogenic Malnutrition in Italy), the most recent and extensive study carried out in the hospital setting, found an average overall prevalence of malnutrition in 30.7% of patients, rising to 34.3% in the elderly (over 65 years of age), more frequent in Medical units (37%) than in Surgical ones (23.3%) and higher among women. In the patients studied, the prevalence of malnutrition was higher than that of obesity.

The European Society for Clinical Nutrition and Metabolism (ESPEN) has reaffirmed, with level A evidence, that the clinical impact of malnutrition is characterized by an increase in complications (infections, delayed wound healing, pressure sores, etc.), reduced functional capacity and a worsening of patients' quality of life. All of this, in turn, leads to more hospitalizations, longer hospital stays, higher mortality and morbidity and, ultimately, increased healthcare costs.

WHICH MALNUTRITION

The consequences, however, differ according to the type of malnutrition; they are smaller in the case of protein-energy deficiency (marasmus), as occurs in fasting, where the body adapts by conserving substrates; they are greater when undernutrition is combined with stress (illness, surgery, etc.), a condition in which mortality occurs earlier and treatment is less effective.

Finally, it should be remembered that malnutrition is also associated with psychological deficits, with progressive cognitive decline, apathy, depression and bed confinement, which set up a vicious circle with anorexia and difficulty eating, leading to a further worsening of the situation.

A PROBLEM THAT GOES UNHEARD

In this context, by now so well defined scientifically and so economically decisive, the ignorance of malnutrition shown by those responsible for steering healthcare resources towards appropriate use is dismaying — and even more so on the part of the medical profession, which regards fasting as an almost inevitable procedure for hospitalized patients, even in the presence of increased energy expenditure (e.g. fever).
The merit of the judiciary (regardless of the outcome of the trial) has been to take notice of a condition too often ignored by those entrusted with the health of Italians. We hope this conviction will help open eyes and minds to this problem.

The Nutricity scientific committee