WHO calls for nutrition support integration into all levels of healthcare
As outlined in the previous articles in this series on Disease-related Malnutrition (DRM), the WHO1 and the international clinical nutrition professional community consider DRM an urgent health priority, but one that remains inadequately addressed.
DRM is a wasteful drain on national healthcare resources and quality of care, and impacts significantly on the health outcomes of individual patients. The resulting healthcare burden is unsustainable and unaffordable for a resource-limited setting such as South Africa, which also faces a disproportionately high DRM prevalence. Importantly, DRM is highly amenable to medical nutrition therapy intervention with quantifiable impacts on clinical outcome indicators and significant cost savings.
The WHO1 therefore outlines in its call to action the efforts expected of policymakers to address this nationally. These include:
• Policy recognition of DRM as a strategic priority topic to be addressed;
• Implementation of comprehensive and optimal clinical nutrition care screening, intervention and monitoring at every level of healthcare and through the entire patient care journey; and
• Strengthening the insight and knowledge of DRM among healthcare professionals
The ethical imperative to respond to DRM
The argument that nutrition and nutritional care is a basic human right is accepted by the clinical nutrition community worldwide. DRM is the point at which the right to nutrition and the right to health intersect. Internationally, this is upheld in the so-called Vienna Declaration2, co-signed by multiple members of national professional nutrition societies and bodies.
To date there has been no DRM position statement or policy framework published for the South African context, despite the rights to freedom from hunger and malnutrition being enshrined in the Constitution.
International guidelines3 affirm that nutritional care is as essential as medical treatment, while the South African Health Act upholds the professional and ethical duty of care of health professionals.
Accumulated evidence shows that DRM has negative impacts on health, recovery, meaningful clinical outcomes, quality of life and the realisation of human potential across the lifespan. Thus, within a human rights health framework, nutrition and fluids should be part of medical treatment, and patients with the particular vulnerabilities conferred by DRM should be afforded the demonstrated benefits of medical nutritional care for this condition. Therefore, the current lack of comprehensive hospital-wide screening and universal access to reimbursed medical nutrition therapy denies patients their fundamental right to food and to health.
Barriers to action in resource-limited settings
DRM is of special contextual concern in South Africa because of the additional contributing factors inherent in a low- and middle-income society. These include underlying socioeconomic and food security-related drivers, and the increasing burden of NCDs such as HIV/Aids, tuberculosis, and chronic diseases. South African also faces barriers such as lack of equipment, shortages of skilled healthcare professionals including dieticians, low training of healthcare professionals in clinical nutrition, and institutional de-prioritisation of nutritional issues.
Practical solutions include empowering of nurses to screen for DRM, embedding DRM detection into routine clinical care, and enhanced multi-disciplinary collaboration around clinical outcomes linked to DRM.
Need for cohesive policy and health protocol response
Policy and funding of DRM-related interventions have not kept pace with the advanced clinical nutrition treatment protocols of medical conditions. Low and middle-income countries such as South Africa carry a disproportionately high DRM burden but with fewer healthcare resources.
In such resource-limited settings, medical nutrition therapy is one of the most inexpensive interventions in medicine, with the capacity to leverage very large short- and long-term savings making it a compelling health investment.
In this regard, DRM management reduces the demand for and utilisation of other aspects of the health system, including visits to primary care doctors and clinics, the need for after-hours health services, reduced medication use and reducing use of hospital resources. This has the effect of extending limited health sector supply.
Importantly, data from low and middle-income countries show that delays in the initiation of nutrition therapy in DRM leads to progressively lower cost-effectiveness. This emphasises that early intervention is imperative not only from a clinical viewpoint, but an economic one as well.
Responsive and responsible action
Recognising DRM as a national health priority and embedding nutritional care into South Africa’s healthcare system is urgent. It is not only a clinical necessity but also a constitutional and ethical obligation, with significant implications for patient outcomes and national health economics.
Collaboration between the Department of Health, medical aids, professional societies, universities and other stakeholders is essential for a coordinated response. Development and implementation of resource-stratified guidelines tailored to local contexts as well as investment in training and resources to empower frontline healthcare staff are key elements.
While mandatory screening and nutritional support for DRM in all hospitals is the goal, assurance of funder reimbursement of medical nutrition is critical to ensure that widespread implementation is achievable in all state and private facilities. It is of relevance that the WHO has recognised DRM as a distinct clinical entity and assigned it a specific ICD codeset. This makes their call to action actionable, because ICD-coding will give this clinical condition equal status with all other recognised diagnoses and compel enhanced attention to it in health funding.
ENASA — the Enteral Nutrition Association of South Africa — advocates for the recognition and treatment of disease-related malnutrition across South African healthcare settings. Visit enasa.org or contact chairperson@ena-sa.co.za | +27 66 269 1173
References
¹ WHO/EURO:2023-8931-48703-72392
2 Cardenas et al, 2023
3 Cederholm et al, 2019