Disease‐related malnutrition in the twenty‐first century: From best evidence to best practice

Malnutrition is a syndrome that results from the intake of nutrients that do not conform to physiological requirements. Malnutrition indiscriminately affects individuals across various stages in life, right from infants and children to adolescents and older adults, and includes underand over-nutrition. Whilst under-nutrition was once associated with developing countries and over-nutrition with developed countries, many parts of the world experience a dual burden. Three landmark papers on malnutrition published in the twentieth century include: • ‘Human starvation and its consequences’ by Ancel Keys (1946), that demonstrated when deprived of adequate nutrition, healthy volunteers developed severe physiological and psychological disorders, which improved with the reintroduction of adequate feeding; • ‘The skeleton in the hospital closet’ by Charles Butterworth (1974), that was the first to highlight that, despite a noticeable prevalence, hospital-based medical teams failed to identify malnutrition in patients; • ‘What supports nutritional support’ by Ronald Koretz (1984), that highlighted the knowledge deficit in making evidence-based decisions regarding when acute care patients should be offered nutrition support. These works led to the inception of a huge body of clinical research into malnutrition. Depending on the method of assessment, malnutrition is prevalent in approximately 20–50% of adult acute care patients, 20–70% of nursing home residents and 5–30% of community-dwelling adults. Research has provided compelling evidence associating malnutrition with frequent readmissions to hospitals; prolonged length of hospital stay; increased risk of infections, falls and pressure ulcers; delayed convalescence; increased health-care costs; and mortality. Nutrition screening and assessment tools have been developed and validated to identify and diagnose malnutrition across the continuum of care, with research informing the development of nutrition support and care strategies to manage malnutrition. Working parties and task forces from around the world have compiled, collated and summarised evidence into guidelines to inform best practice amongst clinical staff for the management of malnutrition, which have been endorsed by dietetic associations and societies. The basic premise of evidence-based practice guidelines is to improve and ensure best practice for patient care. Guidelines emerging from clinical research are usually accepted by practitioners at an academic level. Therefore, it is logical that practice would align with evidence-based guidelines. On the contrary, substantive data reflect that practice diverges from evidence-based guidelines. So, where lies the problem?