12. Malnutrition: How to spot the common signs and encourage the best nutrition in loved ones

​[00:00:00] 

Jackie: Nutrition fuels our bodies and minds. Our strength, mobility, energy, and even mood rely on the right nutrition and scientists are continually uncovering new secrets. Welcome to Nutrition Unlocked, the podcast celebrating innovations advancing the role of nutrition and health, sponsored by Nestle Health Science.

In each episode, we talk to experts from around the world about the latest topics in the science of nutrition.

On today's episode, we'll be talking about malnutrition. Our host is Anna Mole. 

Anna: Welcome back to Nutrition Unlocked. 

I'm Anna Mohl, and in this episode, I'm looking forward to diving into the topic of malnutrition. We're joined today by Professor Agathe Raynaud-Simon, a geriatrician and nutritionist who heads the geriatrics department of Bichat University Hospital in Paris. Agathe is also a professor of gerontology and geriatrics at Paris Cité University. 

She coordinated the drafting of the French [00:01:00] High Health Authority guidelines on nutrition in the elderly in 2007 and 2021, and contributed to the Aspen guidelines on clinical nutrition and hydration in geriatrics in 2019 and 2022.  On top of all of that, Agathe takes part in the organization of the Annual Malnutrition Awareness Week for the French Ministry of Health.

A very warm welcome Agathe, bienvenue! 

We are delighted to have you on our podcast, bringing your great depth and breadth of experience and expertise to discuss the important topic of malnutrition. What it is, what causes it, who is most at risk, what role can nutrition play in addressing it, and very importantly, what can we do to prevent it. 

Agathe: Well, let's get started. I think it would be great to get us started by explaining a bit about what is malnutrition and who it impacts.

Well, you can define malnutrition very simply. Malnutrition is what happens when one is ill and loses appetite, loses [00:02:00] weight, muscle mass, muscle strength. So that is something you can see for people around you that you know who are not doing very well when they are ill. You can also have more medical and physiological explanation for malnutrition because malnutrition is a matter of losing muscle. 

The reality of things is when you lose weight quickly, when you are ill, you lose muscle and not so much fat.

Anna: Okay. So that distinction is very important in this situation.

Agathe: Yes. this is why you have to really think about weight loss more than being either fat or not fat.

Anna: I think that kind of sets a bit of the context. You mentioned that malnutrition is often a risk or found in people who are ill. Who are the groups or the populations that are particularly at risk of malnutrition?

Agathe: Well, if you talk about numbers, probably the population that is as at [00:03:00] highest risk for malnutrition is older people. So they are malnourished, not because they are old, but they are at risk of malnutrition because as you age, the chances of having a disease increase. And in older people you might have severe diseases like heart or gut or renal disease or cancer, and also diseases that are not so risky themselves, but contribute to making you eat less. So this is also a cause for malnutrition. Other than older persons as such, the greatest disease for having malnutrition is cancer, where malnutrition affects about 40% of patients with cancer. Also if you go to the hospital and look for the highest prevalence of malnutrition, then you will find them in digestive tract surgery, because people have illnesses of the [00:04:00] digestive tract and they're in surgery, so they're usually not eating very much.

And then you have other situations like maybe people having hip fractures and all severe diseases affecting important organs, such as lungs, the heart, the kidney and the liver. So actually, any disease, as long as it has an impact on the way you're living, makes people at risk for malnutrition.

Anna: That's really interesting. Thank you for that. The data is staggering. I mean, you mentioned 40% malnutrition rate among cancer patients and my understanding is one in four patients in the hospital is malnourished. One in three patients is at risk of malnutrition. So when you put those numbers together, it's quite staggering.

Do we see more malnutrition in the hospital or at home or does the setting of care not really [00:05:00] have an impact?

Agathe: Usually, in a hospital with all specialties, you have between 30 and 40% of malnutrition. So we can use hospital as a sort of filter to screen for malnutrition, but actually probably where the highest number of persons with malnutrition are at home. Especially older people.

5 to 10% of older people living at home are malnourished or high risk of malnutrition. If older people need professional help to stay at home, then the prevalence of malnutrition is like 25%. 

Anna: Okay. Wow. So very significant. 

Agathe: Very significant. In nursing homes it's 35%. The more severe the disease and the older the person, the more malnutrition there will be.

Anna: That's great insight. Let's talk a little bit about why this is so important. I mean,the impact of malnutrition, I think is something that is [00:06:00] often underestimated by those who are not well versed in the disease in terms of the economic, the humanistic and the clinical impacts.

Could you talk a little bit about that?

Agathe: Well, malnutrition has a very uh, strong impact on outcomes for a disease. The first thing is that when you're at home and you are malnourished, the risk of being hospitalized increases.

Second, when you are in the hospital and you go out, if you are malnourished, you will come back more often to the hospital. There are more readmissions in malnourished people. 

Also in the hospital you can have more complications, any complications, but in particular, infectious complication, like infections with the really bad germs in the hospital. And, also it will delay wound healing when you've had surgery or when you have ulcers or pressure sores. And, on the [00:07:00] whole, it will delay recovery from any disease. And of course, malnutrition is associated with a higher risk of death.

Anna: So pretty staggering. And there are a lot of studies, and you've certainly led and participated in and done the work on many of them, also related to you know, healthcare resource utilization of malnutrition at home is much higher in terms of GP visits and healthcare resource utilization at the hospital. And you've already touched a little bit on length of stay, as well as infections, wound healing, things like that. 

Agathe: Yes, well, a person that is malnourished costs a lot more because of these complications and induce longer stays in the hospital, more treatments, more antibiotics, more time for nurses to make bandages for wounds.

And that is important. There has been many studies on cost-effectiveness of treating malnutrition [00:08:00] and all these studies agree and say that, if you treat malnutrition, it doesn't cost very much. 

Anna: Yeah, I think, as you said there, there's lot of studies that show that interestingly, it's not always treated and it would be great to hear a little bit from you about how to look for the warning signs of malnutrition so that our listeners you know, can feel more equipped to spot the symptoms in our loved ones and importantly be able to take action. And, you know, this is whether they're at home or in the hospital because it is not always well diagnosed.

Agathe: Actually, yes, it's difficult for, family members to diagnose malnutrition, because usually it happens slowly, progressively. So actually the best way to detect malnutrition is to monitor weight. But this is not always that simple. You could say that it would be a good thing for measuring weight once a month, maybe not every day of [00:09:00] course, but maybe once a month when you start having problems with your health.

And actually any weight loss should raise a red flag, and the sooner you detect malnutrition, the easier it'll be to treat it. So do not wait to see a person that has lost 10, 15, 20 kilograms. This is already late for starting to care for the nutrition status.

Anna: I think that's really good advice and I think some of the things to watch out for are clothes fitting more loosely, is jewellery becoming loose, reduced appetite. You know, even the little things that maybe it would be easy to overlook, it's probably something that we need to pay a bit more attention to, especially in patients or the family members who might be in a category of greater risk.

Agathe: Yes, you have to remind yourself that when you see loose clothes and loose rings and emaciated face, it means you've already lost a lot of weight actually. [00:10:00] And you want to see weight loss much sooner, because when you've lost three kilograms, five kilograms, it's already time, to have a full, assessment and to try and identify why you have lost weight and what you can do about it. Often people come to see us in the hospital and on visits and they've already lost 15 kilograms. And the family says yes, he's lost weight, but he's lost a lot of weight we try to have it a bit sooner.

Anna: I think you raise an excellent point that you know, the sooner we can identify it and do something about it the better, right? Let's not wait till it gets so severe that you're at, you know, 15 kilo for example. How can we help our loved ones improve their nutrition or help those who maybe have good nutrition, but have a poor appetite and maybe aren't eating enough.

What's some advice that you have?

Agathe: The first thing is to fight against ideas that are thought to be true, but are not [00:11:00] actually, like it's a normal thing to lose weight when you're old or it's a normal thing to lose weight when you have a disease. You see it often, but that doesn't mean it's a good thing.

So the first thing is to know that, because often people say, yes, I've had cancer, but at least I've lost five kilograms. That's not right. You shouldn't lose weight at that moment, because you will lose muscle. So the first thing is to understand that it's not a good thing. 

The second thing is to give counselling for just uh, good sense eating. It is usually advised to have more traditional meals, at least three times a day, have snacks Eat meat, fish and eggs, eat some things that have protein and some things that have enough energy,  just to get to the point of having weight that doesn't change. [00:12:00] Stable weight is the best for  your health. 

 That's great advice. Thank you for that. Are there any supplements or products that people can take to maybe help make it easier, if it's hard to prepare a meal or have a snack? Anything that you recommend to families or patients?

When you lose appetite, it's difficult because eating when you don't have much of an appetite is a difficult thing. So you have to acknowledge this. But in the same way, there are many little ways that you can help somebody who does not have too much appetite and is malnourished to eat better. 

 we have to have a strategy for nutritional care and this strategy will be guided by a full assessment of the patient, particularly diseases, but also the prognosis of the disease disabilities, chewing and swallowing disorders, fungal infections of the tongue, mobility. All this is a whole assessment that will help [00:13:00] us guide the nutritional care. When we know we have to help somebody to put on more weight, the important thing is to inform that patient that better nutrition will help regain strength, prevent complication and promote better recovery. And then do little things that will help this person eat. You can propose food that the person likes, like it's no use giving them cauliflower if they don't like it. So give them something they like at the moment, the person is willing to eat it. So you have to not be too strict with food content or timing, just go with what the person feels like. 

So some people will prefer hot meals, other ones cold meals. They're equally good for nutrition. And, you have to also favour pleasure when eating. And pleasure is the food content, but it's also [00:14:00] the table, also the people you're eating with, the atmosphere. This is probably something difficult to do for everybody, but you don't really eat that much if you don't have pleasure in eating. It has been also proposed to put a variety of foods and different colour, different tastes in the plate. So this will encourage the person to taste a bit of everything. We could also add taste, So you have salt and pepper and mayonnaise and ketchup and mustard and aromatic herbs. I knew an older man who was malnourished and really tired, but what he liked is sugar in the wine. So that was good. And he was French of course. 

Anna: Of course!.

Agathe: And also he used mayonnaise and ketchup in a mixed pink sauce. And this was nice because he didn't have much saliva, so it would help him swallow food more easily. So you just have to adapt to the person.

Anna: I think those are great tips and [00:15:00] tricks and hopefully, people can really think creatively about what are the things that we can do to help our loved ones eat in a creative way. I also really like your point about the importance of pleasure and sociability.

I think when we're trying to think about getting people to eat, it's sometimes, you're so focused on the content of the food that you forget the setting and the context of the food. And I think, you know, making it a pleasurable experience where they wanna participate, where it's a social occasion, I think can be very beneficial. 

What's your thought about the use of oral nutrition supplements or multivitamins or mineral supplements, whether it's addressing malnutrition or optimal nutrition, or something like this?

Agathe: Well, when you have tried with food and even snacks and the weight doesn't increase and the person is still losing weight, you have to go one step further have to first try food densification with energy and protein-rich nutrients, which can be cheese, milk, powder, or eggs or mince [00:16:00] hams or some also sweet things sometimes.

and oral nutritional supplements are interesting, because they are very dense in energy and protein, so this is actually a good way to increase food intake without increasing the volume of the food and these oral nutritional supplements can be given either at the end of a meal or between meals as a snack.

So ONS are a great tool to treat malnutrition, and we use them, a lot. Because, the message that it gives to the patient also is nutrition is important. I'm going to prescribe something that will help you with nutrition, will help you to intake proteins and also vitamins Some people say that ONS are not so well taken. Actually, the compliance to ONS is pretty good. About 80% at home and like more to 60 or 65% in the hospital, which is pretty good [00:17:00] actually.

Anna: Yeah. I think your point about when the doctor, or a nurse or a dietician recommends it, it elevates the importance of it and helps people really understand the important role that nutrition can play in their recovery. And what you're describing really resonates. With me on a personal level. There were years when my father-in-law was losing a lot of weight. We were very worried about him. He was trying to eat, he couldn't keep the weight on. And so he didn't live near us, but we would ship him, cases of an ONS every month. And we would, whenever we talked to him, we would check in and make sure that he was drinking them fast enough for us to reorder them. And that was a bit about how he checked in remotely and it really, it made a difference. And to your point, he really enjoyed the taste. So he looked forward to it. There are a lot of flavor varieties, so he really enjoyed it. And it gave us a little more confidence that he was eating or drinking or consuming something that was, nutritious, that was a little pleasurable for him.

Agathe: Yes. And then, in addition to ONS, we also prescribe vitamin D, because [00:18:00] most people, will have a deficiency in vitamin D if they're not supplemented. And vitamin D is important, of course, for the bone. but It's also good for the muscle 

There are receptors of vitamin D in the muscle and if we want the muscle to function properly, it needs not to be a deficit in vitamin D. 

And finally, is to encourage physical activity. So we are still thinking about the muscle, and the best way to make muscle is to have physical activity, exercise, resistance exercise if possible, just walking your dog is good enough. having something on the bike or any physical activity will improve your muscle status.

Anna: Yeah, I think going back to your earlier points about one of the risks with malnutrition or the impact of malnutrition is muscle loss, so I think this idea of, feed the muscle, use the muscle is something that's really important and having that in combination. So thank you for that advice.

So you talk about [00:19:00] what malnutrition is and the importance of diagnosing it, but how is it diagnosed and what is the criteria in order to get a diagnosis for malnutrition?

Agathe: So if you're a healthcare professional, you need specific criteria to diagnose malnutrition. Actually, since 2019, there is an international consensus on the diagnosis of malnutrition and to diagnose malnutrition, you have to have an association between at least one phenotypic criteria and phenotypic means something you can measure from the body, like weight, BMI and muscle mass, and at least one etiologic criteria, which means you have to have a cause for malnutrition. And so you have phenotypic criteria, which is weight loss. More than 5% of one's usual body weight in one month or more than 10% in six months.

Anna: Okay.[00:20:00] 

Agathe: Low BMI, being too thin, means having too little muscle. So B M I is too low when you are under 20 in adults and under 22 in adults age 70 or over. 

And also you have the third criteria is low muscle mass, but muscle mass is not that easy to measure in clinical practice. It can be estimated by low calf circumference, but it's best measured by specific medical devices like bioelectric impedance or absorptiometry, but these will be done mostly in health, care settings.

And the etiology criteria includes low food intake, low food assimilation. So these are specific digestive tract diseases and inflammation due to acute or chronic diseases. So you have to have at least one criteria in the two categories to make a [00:21:00] diagnosis of malnutrition.

Anna: And the diagnosis, or I should say the assessment to determine if there's a diagnosis what would trigger the assessment?

Agathe: Well, the assessment would be triggered either by symptoms like somebody who's very tired, has difficulty in climbing the stairs or walking slowly or having low appetite. This will make us look for weight loss and all the criteria for malnutrition. And the other situation is having a disease, knowing that disease makes the person at risk for malnutrition.

Anna: So, to wrap things up, I wanted to get your maybe one or maybe two key takeaway points that we can incorporate in our day-to-day routines, whether it's speaking up if you notice someone with unintentional weight loss or helping a loved one to get the best nutrition, or one tip that you think can really make a disproportionate difference in the health and nutrition of our loved ones.

Agathe: Well, maybe one message [00:22:00] is that 

Anna: to prevent and treat malnutrition, focus on the muscle, focus on protein intake and physical activity to maintain muscle mass and muscle strength.

I actually like that summary there of focus on the muscle. 'cause that, to me, it gives me like a visual because you've shared a lot of great information. If you think about, it's all about the muscle. How do we feed the muscle? How do we use the muscle? How do we maintain the muscle? How do we build the muscle? I think that's a great message to take away. 

Well, I think this episode of Nutrition Unlocked has really put into perspective how intertwined nutrition is with overall health. From our social wellbeing to our physical health, to risk of more severe outcomes if we're not well-nourished. 

Malnutrition is such a complex condition and we all likely know someone who's been affected. I hope that today's conversation has really reinforced the responsibility we all have to not only watch out for the common symptoms in our loved ones, but also take [00:23:00] action to assure they're getting the best nutrition possible.

 And Agathe, I think that you provided us with some very simple, practical, actionable tips that we can all do something with. So again, thank you so much Agathe for sharing your insights, expertise, and practical tips that we can all put into action starting today. It's really been such a great pleasure speaking with you. I learned a lot and I'm sure our listeners have as well.

Agathe: Thank you. It was a pleasure for me too.

Anna: Thank you to all of our listeners for joining today. If you haven't already done so, please subscribe to Nutrition Unlocked so you don't miss a single episode and we'd love to hear from you. So use the hashtag, #nutritionunlocked on social media to let us know your thoughts on this episode or the favourite insight that you've learned.

We look forward to sharing more insights on the science of nutrition with you very soon, and we look forward to seeing you next time on Nutrition Unlocked.

[00:24:00]