German 
Hospital food affects chances of recovery — often for the worse
Every fourth hospital patient is affected by malnutrition. The consequences — more complications, worse healing processes, higher mortality rates — are scientifically well described. Politically, however, the problem is largely ignored. The corona pandemic is also an opportunity to change this.
When the US Agency for Research and Quality in Health Care (AHRQ) presented its major systematic review on malnutrition in clinics in October last year, it saw a lot of clear evidence: that malnourished patients who have to go to the hospital because of a serious illness , have to reckon with worse healing processes. They are more likely to have complications. The US authorities also found clear indications that they have to stay longer in the hospital and that the mortality rate among them is higher compared to well-nourished people. She had evaluated studies from 20 years.
Malnutrition in the hospital: one in four affected
In Germany, the German Society for Nutrition (DGE) tried in 2019 to bring the topic of malnutrition among patients in hospitals into public discussion. This is a “relevant health issue” with “serious consequences,” she warned. Also because it is by no means a marginal phenomenon. On “Nutrition Day” 2018, the initiative of the same name to examine the nutritional situation in clinics, the DGE evaluated information on 767 patients in 48 German hospital wards for a specific date. She classified more than 35 percent of the patients as malnourished using international criteria. Studies repeatedly estimate the proportion of patients with a significant risk of malnutrition to be a quarter of all hospital patients or even more.
There are clear findings on the consequences of malnutrition — including increased susceptibility to infections, impaired wound healing, longer recovery processes, increased mortality. The Austrian nutritionist Angelika Beirer evaluated worldwide research on malnutrition and cancer for a review published in 2021. On this basis, she comes to the conclusion that in up to 20 percent of deceased cancer patients, the cause of death is not their disease, but malnutrition. Other studies came to even higher proportions.
Hospital Food: The “Elephant in the Room”
For the US oncologist Declan Walsh, this topic in cancer medicine is the “elephant in the room”: Everyone knows that it is there – but nobody really takes care of it. The observation can be transferred to many other medical fields. In addition to tumor patients, people with gastrointestinal diseases and geriatric patients (elderly medicine) are particularly affected by malnutrition. Older people, who often lack sufficient protein, are more likely to fall and have functional limitations, and they die more often in hospital than people who are normally fed, regardless of age, as suggested by an evaluation published a few months ago by the Esslingen University of Applied Sciences.
In short: The topic of malnutrition in the clinic is “essential for millions of patients,” comments Martin Smollich, Professor of Pharmaconutrition at the University Hospital Schleswig-Holstein — “and yet not on the political agenda of any party.”
This was by no means always the case. In 2003, the Council of Europe passed a resolution calling the number of malnourished hospital patients “unacceptable”. Attached: a long list of urgent recommendations on what to do about the problem. What became of it, almost 20 years later?
The Federal Ministry of Health has “no knowledge” about this, it said on request. So far, there has been no need for political action anyway: “The clinics are responsible for the catering in the hospital themselves within the framework of their organizational sovereignty. In this respect, healthy and patient-oriented catering appears to be an aspect in which the hospitals are involved in the competition for patients in their own interest,” it said in mid-2020, still under the leadership of the CDU politician Jens Spahn Ministry response to a parliamentary question. When asked by MedWatch in January 2022, a spokeswoman said it “didn’t have anything to add to the positions today”, but also referred to the new government’s short term in office and the fact that the priority was to fight the pandemic.
Malnutrition and Pandemic
But the topic is particularly important for fighting the pandemic: initial studies indicate that malnutrition is a risk factor for severe COVID-19 courses. From the point of view of the European Society for Clinical Nutrition and Metabolism (ESPEN), malnourished people are among the groups with the highest mortality from COVID-19, which is why the society advocates consistent screening and the integration of nutritional therapy into treatment. The Federal Ministry of Health once again explains the role of malnutrition in the pandemic: “We have no knowledge of this.”
The associations are demanding changes from medical school to clinical practice. For example, universities should set up chairs for nutritional medicine and bring the nutritional content, which has only been rudimentary so far, more into the curricula — the federal representation of medical students recently supported this in a position paper. In many health professions, right down to the doctors, there is a lack of competence in nutritional matters.
Professional societies are further along. They are not only currently demanding consistent nutritional management in the clinics for people with COVID-19, but have been doing so for a long time. “70–80 percent of all diseases have a nutritional cause, a nutritional background or a nutritional therapeutic consequence,” says a paper by the Federal Association of German Nutritionists (BDEM), the German Society for Nutritional Medicine (DGEM) and the German Academy for Nutritional Medicine (DAEM). (Also read our interview with Johann Ockenga. He is Director of Medical Clinic II at the Bremen-Mitte Clinic, President of the Congress of the German Society for Nutritional Medicine (DGEM) and co-author of several guidelines on clinical nutrition).
Costs in the billions in the healthcare system: When the issue of malnutrition in hospitals made it onto the political agenda, it was primarily for economic reasons that prompted it. Like in 2009, when an international conference invited by the Czech EU Council Presidency set the goal of “stopping” malnutrition.
Earlier, Olle Ljungqvist, then President of the European Society for Clinical Nutrition and Metabolism (ESPEN), published an estimate that malnutrition caused annual costs in European healthcare systems of at least 170 billion euros. For this information, the surgeon had extrapolated British data. There are no exact dates to this day. In 2007, the management consultancy Cepton estimated the costs incurred in the German healthcare system at nine billion euros in an industry-related study. The largest part – five billion euros – arises in the clinics as a result of higher treatment costs and longer stays. Which is why it might even be economically advantageous for the hospitals to invest in nutritional therapy: With a comparatively manageable use of resources, lengths of stay could be shortened and the costs for the more complex treatment of malnourished people reduced.
The Association of Dieticians (VDD) also spoke to MedWatch in favor of anchoring nutritional therapy in the flat-rate system used for hospital financing (DRG) and binding service descriptions. Patients would have to be screened for malnutrition, and the food would have to be adapted to individual needs: many associations agree on this.
From the point of view of the VDD, every clinic should have its own department responsible for nutritional management — based on the model of physiotherapy. As there, doctors should also be able to issue prescriptions for nutritional therapy in the outpatient area if necessary, so that this would be covered by health insurance: “This is the only way to combat malnutrition where it usually occurs – namely in the home environment”, says VDD President Uta Koepcke.
Hospital food: Five euros for groceries a day
The trend is rather the opposite. It’s time to save costs at the clinics: according to a survey by the German Hospital Institute, they spent around five euros per day and person on food in 2018 — price-adjusted 14 percent less than in 2006. There are no binding quality specifications for the catering. The jobs for dieticians are also declining significantly. In the 2018 survey evaluated by the DGE, just five of the 48 participating stations reported that they had corresponding positions.
There is no lack of proof of medical benefit. With nutrition tailored to the individual needs of the patient, competent nutrition teams can improve the well-being and chances of recovery of the sick, shorten their suffering and increase the chances of survival. This is confirmed by a Swiss study. For the study published in the journal The Lancet, the research group conducted an intervention study between 2014 and 2018 with around 2,000 patients at eight clinics in Switzerland. The patients had come to the clinic with different diagnoses — infections, cancer, cardiovascular, gastrointestinal, lung, kidney or metabolic diseases — and also showed signs of malnutrition.
In the study, half of the patients received the usual hospital food. For the other half, dietitians tailored the diet to individual needs, particularly in terms of calorie count, protein content, and nutrient content, and they gave people advice. This had an effect: after 30 days, people in the group receiving nutritional therapy had a 21 percent lower risk of serious complications or a significant deterioration in their state of health than those patients who received the usual hospital food.
Nutrition therapy reduces mortality
Despite the short duration of the intervention, a change in diet could already make a difference in the few days of the hospital stay — in case of doubt a decisive one: In the Swiss study, ten percent of the people who were treated with normal hospital food had died after 30 days. In the intervention group, this applied to “only” seven percent. The risk of dying during this period was reduced by 35 percent with nutritional therapy. In case of doubt, consistent intervention could make the difference between life and death.
In case of doubt, consistent intervention could make the difference between life and death. In her review, she confirms the “evidence that malnutrition-targeted, hospital-initiated interventions are likely to reduce mortality and improve quality of life compared to conventionally managed patients.”
Nevertheless, the coalition agreement of the traffic light alliance does not address the problem of malnutrition in clinics. “The implementation and the corresponding financing of improving nutrition in hospitals and care facilities were not specifically agreed,” said the deputy leader of the Greens in the Bundestag, Maria Klein-Schmeink, on request. “These questions will be addressed as part of the nutrition strategy.” Such is announced until 2023.
There is another starting point in the contract: the coalition wants to “establish” the quality standards of the DGE as a standard in mass catering. What is meant by whether the traffic light wants to make the recommendations for a balanced diet in clinics a legal obligation remains open — even after asking all coalition parties.
“Yes, the DGE standards should be introduced as binding,” says Katja Pähle, SPD parliamentary group leader in the state parliament of Saxony-Anhalt and her party’s lead negotiator for health policy in the coalition agreement. However, there is “only a basic agreement” between the traffic light partners – which facilities are meant “is still to be clarified in detail”. From Pähler’s point of view, hospitals and nursing homes should be part of it: she would “like to work for it”.