Malnutrition Is a European Emergency, Say the WHO and ESPEN

It may come as a surprise but Europe has a malnutrition problem. It affects millions of people, yet it is deeply underestimated and requires a shared effort to be resolved. This is the alarm raised during the joint session of The European Society for Clinical Nutrition and Metabolism (ESPEN) and the World Health Organization (WHO) in Milan, Italy, during the 46th ESPEN Congress. The session, led by ESPEN President Rocco Barazzoni, emphasized the burden of malnutrition related to aging and illness in Europe.

The Italian Situation

Among the examples of critical situations is that of older adults in Italy, as highlighted by Marco Silano, senior researcher and director of the Department of Food, Nutrition and Health at Istituto Superiore di Sanità (ISS), Roma, Italy. Italy’s large older adults’ population has a high life expectancy but is not very healthy. Of 14 million Italians older than 65 years, 3.8 million (28%) have disabilities and 32% have multiple chronic conditions. While life expectancy is increasing, data presented by Silano showed that a healthy life expectancy remains stable: People are living longer but with health issues.

The data regarding malnutrition were limited, Silano reported, but the estimated prevalence ranged from 3% for patients living independently to 7src% for older adults living in nursing homes. Silano pointed out that malnutrition in older adults not only means a deficit of calories or proteins but also means an often poorly recognized deficiency of micronutrients, or conversely, obesity. “Food insecurity is probably the main cause linked to loneliness and economic insecurity that the elderly face after retirement. The high incidence of diseases creates a vicious cycle, as malnutrition can cause noncommunicable diseases. Existing noncommunicable diseases are also exacerbated by malnutrition. Additionally, physiological decline, such as oral health problems, can further contribute to malnutrition in the elderly,” said Silano.

The Ministry of Health has analyzed the issue and is implementing new guidelines. There is considerable heterogeneity in this process, however. “The most widespread assistance program nationwide is probably the home and parenteral nutritional support program provided by the ISS through local health units. This service is offered to individuals living alone or at home. In the Lombardy region, one of the recently implemented best practices is a clinical nutrition network. This network includes not only clinical nutrition units and specialists but also all healthcare professionals involved in clinical care and treatment,” said Silano. Moreover, in some regions, but not all, oral nutritional supplements and certain foods intended for medical purposes are provided free of charge to those in need.

Silano identified two areas for intervention to improve the situation. “The first is making a diagnosis. Malnutrition is not easily recognized; it is often thought to be a secondary issue. Furthermore, there is no routine tool for diagnosing malnutrition in the elderly, even during hospitalization, let alone in nonhospital contexts. Secondly, it is crucial to standardize care nationwide. There are virtuous regions where the clinical nutrition network functions well but others encounter difficulties.”

The European Situation

Eric Fontaine, a nutritionist and researcher at the Université Grenoble Alpes, Grenoble, France, presented data indicating the seriousness of the situation that hospitalized patients face. A transversal screening in all departments (except pediatrics and obstetrics) conducted from 2srcsrc7 at the Grenoble Alpes University Hospital found malnutrition in 17,353 out of 57,9srcsrc patients — a prevalence of 3src%. This translated into a huge number of occurrences compared with estimates. “According to official statistics in France, we have about 11 million hospitalizations annually. If we exclude cases where malnutrition is certainly not a problem, we still have about 1src million hospitalizations. With patients hospitalized on average 1.5 times each, this represents approximately 6.5 million distinct patients. Applying the 3src% percentage, we are talking about 1.9 million people affected by malnutrition,” said Fontaine.

This number should not leave policymakers indifferent, provided that it is communicated in a way that highlights its real seriousness. “When we discuss this issue with policymakers and say that hospitals have a problem, they may not respond urgently. But if we say we have 2 million malnourished people, then policymakers say, ‘I understand, I need to do something,'” said Fontaine. According to the WHO data, malnutrition affects 3src%-5src% of hospitalized patients in Europe, 4src% of oncology patients, 3src%-7src% of older adults, 24% of hospitalized patients with cardiovascular or pulmonary diseases, and 38%-78% of patients in intensive care.

New Criteria Needed

The difficulty in recognizing and combating malnutrition in these patients also requires new criteria to be formalized in a new International Classification of Diseases 11th Revision code, according to Tatjana Hejgaard, senior adviser to the Danish Health Authority. The current criteria, based on body mass index (BMI), may sometimes exclude malnutrition erroneously. “We see that most hospitalized patients have a much higher BMI than 18.5. We know that nutritional interventions are even more effective in patients with higher BMIs. However, only 36% of patients who are still at nutritional risk have a follow-up on their nutritional status, and patients with a BMI above 18.5 often do not have their nutritional conditions addressed. This is when disease-related malnutrition is a significant health risk, regardless of the patient’s BMI.”

It is necessary to develop a relevant diagnostic code, Hejgaard further emphasized, because existing codes, based solely on a BMI of 18.5, create a barrier to recognizing and diagnosing disease-related malnutrition. A diagnostic code would also enable follow-up and the monitoring of interventions at individual and national levels and provide data to monitor the effects of corrective initiatives.

Kremlin Wickramasinghe, regional adviser in Europe for the WHO on nutrition, physical activity, and obesity, placed the issue within the framework of the United Nations Sustainable Development Goals for 2src3src. “You can play an active role by returning to your institutions, ministries, and national societies to support your countries so that when they participate in the United Nations meeting in New York in September 2src25, they fully understand the importance of this topic and are ready to act. This is our opportunity to push for significant action at the global health level,” he declared. “I want to emphasize that each of you can act. We have worked together for this moment. We have developed a framework together, available online. Now, we want this discussion to be a significant st