Expert Q&A: Is enough being done to address disease-related malnutrition?

In Europe, 33 million are at risk of malnutrition,

Ljungqvist O, de Man F. Under nutrition – a major health problem in Europe. Nutr Hosp 2009; 24(3): 368-70.



including 1 in 4 people in hospital.

Russell C, Elia M. Nutrition Screening Week in the UK and Republic of Ireland in 2011. Hospitals, care homes and mental health units. Redditch, 2012.
Russell C, Elia M. Nutrition Screening Survey in the UK in 2008: Hospitals, Care Homes and Mental Health Units. Redditch, 2009.
Schindler K, Pernicka E, Laviano A, et al. How nutritional risk is assessed and managed in European hospitals: a survey of 21,007 patients’ findings from the 2007-2008 cross-sectional nutritionDay survey. Clin Nutr 2010; 29(5): 552-9
Meijers JM, Schols JM, van Bokhorst-de van der Schueren MA, et al. Malnutrition prevalence in The Netherlands: results of the annual Dutch national prevalence measurement of care problems. Br J Nutr 2009; 101(3): 417-23
Russell C, Elia M. Nutrition screening survey and audit of adults on admission to hospitals, care homes and mental health units. Redditch, 2008
Russell C, Elia M. Nutrition Screening Week in the UK and Republic of Ireland in 2010. Hospitals, care homes and mental health units. Redditch, 2011
Imoberdorf R, Meier R, Krebs P, et al. Prevalence of undernutrition on admission to Swiss hospitals. Clin Nutr 2010; 29(1): 38-41.

Addressing disease-related malnutrition involves more than recognising the problem. Illness can increase the body’s nutritional requirements and also impact nutrient utilisation. At the same time, appetite and food intake often decline, making it difficult for patients to get the nutrition they need. When these increased needs cannot be met with normal food alone, medical nutrition containing high-quality protein can play an important role in helping to support muscle preservation and recovery. Understanding how protein quality and digestibility as well as product formulation influence nutritional solutions is therefore key to developing effective nutritional support for patients.

So, with millions of patients affected by disease-related malnutrition globally, are we doing enough to address it? And how can evidence-based medical nutrition and innovation help improve patient outcomes?

This Malnutrition Awareness Week, we spoke to two of our medical nutrition specialists, Danielle van Aarle, Global Marketing Lead, Medical Nutrition, and Thom Huppertz, Research Fellow, Dairy Science and Technology to find out more.

Why does disease-related malnutrition often go untreated?

Danielle: Malnutrition tends to be seen as a symptom of the disease, so people don’t realise it can – and needs to be – treated in its own right. Implementation of routine nutritional screening and diagnosis of malnutrition are key, but this is not always integrated in clinical pathways. Awareness among some healthcare professionals is still limited.  And in multidisciplinary teams, it isn’t always clear who owns the nutritional diagnosis. As a result, nearly half of adult inpatients receive no special nutritional care, despite being malnourished.

World Health Organization Regional Office for Europe (WHO/Europe) (2024). Disease-related malnutrition: WHO/Europe factsheet highlights neglected challenge. 9 September 2024. Available at: https://www.who.int/europe/news/item/09-09-2024-disease-related-malnutrition–who-europe-factsheet-highlights-neglected-challenge



 

Thom: Two things – illness and malnutrition – often arrive together, and that is what makes this so difficult. Then there is the perceived acceptance. Weight loss and reduced appetite are treated as part of the disease pattern, something that comes with being ill. That’s the circle we need to break.

What are the consequences of disease-related malnutrition?

Thom: As appetite decreases, nutrient intake falls. At the same time, the way the body uses the nutrients it does receive, changes for the worse. So, essentially, at the exact point where a patient needs additional nutrients the most, less is going in and it’s being utilised less efficiently. Linked to this, another consequence is loss of muscle mass – which happens particularly when protein intake is insufficient. This can have a profound impact on a patient’s ability to regain their independence, including things like getting out of bed. A patient with muscle loss may have harder time in rehabilitation, so the effects reach well beyond the ward.

Danielle: Malnutrition has a significant health impact on patients and is linked to poorer clinical outcomes. Patients can have an increased risk of infections, poor wound healing and impaired immune status. As a consequence, they could lose their independence and mobility, which in turn negatively affects their quality of life. Disease-related malnutrition can go hand in hand with higher complication rates, delayed recovery, longer hospital stays and more readmissions,

ESPEN (2026), Disease-Related Malnutrition fact sheet, available here: Fact Sheets



as well as increased risk of mortality.

Mori et al., Clin Nutr 2023;42(2):166-172.



For health systems the bill is considerable: malnutrition costs European countries an estimated €170 billion a year.

ESPEN (2017), ‘Oral Nutrition Supplements (ONS) to Tackle Malnutrition’, Medical Nutrition International Industry.

How can medical nutrition help, and why is protein for muscle preservation so important?

Thom: The body is continuously breaking proteins down and rebuilding them in our bodies to support vital functions, from immune responses and tissue repair to maintaining muscle mass and strength. Muscle health plays a particularly important role in maintaining physical function and overall health, making its preservation a key consideration in medical nutrition. But when protein intake falls short, muscle protein breakdown may not be compensated by sufficient muscle protein. This becomes more challenging as we age, because older muscle tissue responds less readily to triggers that normally stimulate muscle growth or repair. This is called anabolic resistance. So, an older patient needs higher amounts of high-quality protein simply to ‘hold their ground’.

As well as muscle preservation, protein is also important for maintaining a healthy immune system and organ function, or repairing damaged tissue and healing wounds, all of which can be important during recovery from illness. Protein isn’t the whole story, though. Micronutrients also play a role, and so does getting enough energy – i the body needs these things to function properly and support essential bodily processes. Medical nutrition needs to provide the right balance of all key nutrients to support these needs and address malnutrition.

Let’s look closer at protein – does quality matter as much as quantity?

Thom: The body needs amino acids to synthesize proteins, repair muscle, support enzyme activity, hormone production and immune function, as well as maintain and repair tissues. But we can’t make all amino acids ourselves – some have to come from our diet. These are called the essential amino acids. One of them, leucine, acts as the ignition for muscle protein synthesis: it is the amino acid that switches the process on. If some of the essential amino acids are low or missing, the body can’t build protein properly. That’s why protein quality and digestibility are important. If the nutrients can’t be used, they can’t help the patient.

A high-quality protein is one that contains all essential amino acids, specifically in proportions that meet the levels the body needs, as defined by the FAO and WHO. Some protein sources fall short of this reference. But dairy proteins are considered high-quality because they offer a complete amino acid profile – meaning they meet these standards. They also offer high digestibility and are easily broken down and absorbed by the body, which makes them a strong choice of protein for muscle recovery and supporting the immune system. Whey and casein each have a role, and they often work best together. Importantly for medical nutrition solutions, casein holds up well under heat, making it a useful protein source in products that require heat treatment to ensure safety and shelf stability. Meanwhile whey protein releases faster, making its amino acids available to the body sooner. The right choice for formulation depends on the product format and on who it’s for.

Danielle: Exactly. Dairy protein remains the gold standard for this reason, particularly for critically ill patients. Plant proteins have a place too, depending on the patient need, but matching the amino acid profile of dairy usually means blending several sources, and that could bring formulation challenges such as viscosity, stability and off-flavours. It’s all about delivering the right protein, for the right patient, at the right moment in their journey.

Some studies show that almost half of patients in hospital do not eat the full meal they are given.

Hiesmayr, M. et al. (2009). “Decreased food intake is a risk factor for mortality in hospitalised patients: The NutritionDay survey 2006.” Clinical Nutrition, 28(5), pp. 484–491



How can oral nutritional supplements and, if needed, enteral tube feeding help? And how can they be designed so patients keep taking them?

Danielle: The recommended daily protein intake for older malnourished patients with an acute or chronic condition is 1.2 to 1.5 g of protein per kg of body weight per day – which is quite high and can be challenging to meet through the normal diet.

Deutz N et al., Clin Nutr 2014;33(6):929-36.



That’s where specialised medical nutrition can play a role. High in energy, protein and important nutrients, medical nutrition solutions can be developed into formats that meet a variety of different patient needs. For example, many patients have small appetites or trouble swallowing, and sometimes both, so product design has to work around that. An example is ONS in a compact format with the right viscosity, delivering a high amount of protein in a small volume. The first questions are ‘what does this patient need, how much do they need, and can they take it by mouth or do they need tube feeding?

With oral nutritional supplements, taste, texture and portion size are all important considerations because they influence whether someone continues taking them throughout treatment. With tube feeding, digestion and tolerability come first. This is because tube feeding delivers nutrition directly into the gastrointestinal tract. Patients need to digest and absorb the nutrients and tolerate the volume and rate of delivery without issues such as nausea or diarrhoea. This is particularly important for those who are already unwell or nutritionally compromised. Importantly, however, whatever gets developed has to be backed by science and defensible in a clinical setting – in Europe, for example, reimbursement bodies increasingly expect clinical evidence.

How is medical nutrition evolving to meet patients’ needs?

Thom: One of the key challenges is fitting more protein per serving into smaller formats, like drinks and shots, without making a product too thick or hard to drink. This helps patients with reduced appetites to finish a serving. For formulators, that means keeping viscosity low, choosing ingredients with a neutral or creamy taste, and making sure the formula stays safe and stable through processing.

Danielle: In Europe, we are seeing a move towards more compact formats and wider choices – including shots and puddings. We’re also seeing savoury options start to appear. Patients can get bored of the same few flavours and formats, especially if you need to take them for a long period. Variety helps to increase patients’ compliance, helping them stick to the prescribed amount they need to take, for the duration they need to take it.

In your view, what needs to change to improve care for disease-related malnutrition?

Danielle: Screening needs to be written into the protocol from the moment a patient is admitted to hospital or other clinical setting. Disease-related malnutrition isn’t a prevalent challenge because healthcare professionals overlooking it – it’s because identifying nutritional risk doesn’t always easily translate into action. It is about building screening into the pathway, giving everyone on the care team a clear role and embedding accountability for nutritional care. Educating patients and families helps too, because more people now look for information themselves, and that can help break the cycle of underdiagnosis. 

Thom: Awareness, education and alignment between colleagues matter just as much as screening and diagnosis, so that everyone involved understands their part in nutritional care. That’s why initiatives like Malnutrition Awareness Week are important – it offers a chance to remember that nutrition should be a routine consideration, rather than an afterthought. Treating malnutrition early can improve rehabilitation and prevent serious issues. That is why prehabilitation, preparing the body before treatment begins, should sit alongside rehabilitation in the conversation.

How can the nutrition industry help improve outcomes for patients?

Danielle: The industry’s biggest contribution is developing products with proven health benefits that people actually want to eat: nutritionally complete, with a good sensory profile and flavours that go beyond chocolate and vanilla. For many patients, these products are their main – or sometimes only –source of nutrition, so completeness and palatability both have to be paramount. Our part, at FrieslandCampina Ingredients, is supporting innovation with the right, science-backed ingredients. Researching protein functionality and working with scientists, universities and customers to validate its benefits – none of this works in isolation. It comes down to the nutrition industry, healthcare professionals and researchers working together.

Want to learn more about our work in medical nutrition?

Explore more insights here