Undernutrition: Dr Ronan THIBAULT, hepato-gastroenterologist and nutritionist answers our questions [1/2]Clinical Nutrition
In 2022, undernutrition is a disease that affects 2 million French citizens  and up to 40% of hospitalised patients . In this article, discover the interview with Doctor Ronan THIBAULT, hepato-gastroenterologist, nutritionist and doctor in Life Sciences, and professor of Nutrition, who talks about undernutrition in his daily life and the levers for adapting and responding to patients’ needs.
Ronan Thibault is a hepato-gastroenterologist and nutritionist, a doctor in Life Sciences and a professor of Nutrition. He is currently in charge of the Nutrition Unit, the labelled home parenteral nutrition centre, and president of the Comité de Liaison Alimentation Nutrition at the University Hospital of Rennes, and responsible for teaching Nutrition in Health at the University of Rennes. He is a member of the Scientific Council of the Faculty of Medicine. He has supervised 25 thesis or master’s works for scientific or medical degrees. He has received a total of 2.2 million euros in grants for 16 research projects as principal or associate investigator. His research interests are: human nutrition, hospital feeding and undernutrition, body composition, artificial nutrition in intensive care, intestinal metabolism. He carries out his research at the NuMeCan Institute (Nutrition Metabolism Cancer), INSERM, INRAE, Univ Rennes.
Pr Thibault was a permanent member of the scientific committee of the European Society of Clinical Nutrition and Metabolism (ESPEN) and was president of the educational committee of the French-speaking Society of Clinical Nutrition and Metabolism (SFNCM), and a member of its Board of Directors.
He is the author of 150 publications in national and international scientific journals and books.
In your opinion, what is the profile of the patient affected by undernutrition? What are the pathologies most often linked to undernutrition?
Undernutrition can affect anyone, whether they are acutely ill or chronically ill, whether they are in hospital or at home. Today, 30 to 40% of hospital patients are affected by undernutrition. The Collectif de lutte contre la dénutrition estimated that there are about 2 million undernourished patients in France.
We follow patients on artificial nutrition, but not all undernutrition will necessarily be treated by artificial nutrition, including enteral and parenteral nutrition.
Patients affected by undernutrition and treated by artificial nutrition are most often oncology patients and patients with neurological/neuromuscular diseases. Medical or surgical oncology refers to patients with sequelae or treated digestive/ ENT cancer. Neurological diseases include patients suffering from the after-effects of stroke or neurodegenerative diseases. In hospital, all resuscitation, perioperative and especially postoperative situations, whatever the discipline, but especially digestive or ENT surgery, and cardiac surgery in some cases, will be complicated by undernutrition, and this can last up to several months, especially for digestive surgery.
On the other hand, in a broader sense, undernutrition is accentuated by the age factor, in fact, 40 to 50% of patients over 70 years of age are affected by undernutrition compared to 20/30% of younger patients.
Are there more patients than 10 years ago or are they just better diagnosed? In relation to the number of patients who are actually undernourished, are more of them being diagnosed today?
I think this is not necessarily the case, unfortunately, it depends on what we call diagnosis. In the field, we have the impression that the teams pay more attention to the nutritional status of their patients. But the Ministry’s figures communicated by the hospitals indicate that there are no more diagnoses of undernutrition, because the coding of undernutrition indicates figures that are much lower than the reality. The Ministry’s vision is the coding via the PMSI (Programme de Médicalisation des Systèmes d’Information), a tool for describing and measuring hospital activity from a medico-economic point of view. So, if we look at this, we are clearly below, 5% on average in a hospital, whereas all the observational studies in the world indicate a prevalence of undernutrition of 40%.
However, colleagues are perhaps more aware of undernutrition today. I think that more oral nutritional supplements are prescribed than before. As far as artificial nutrition is concerned, I think there is a stagnation.
I think it has to be said that we are far from overcoming the situation and that it is still an under-recognised disease. There are still fears, particularly among caregivers, in relation to preconceived ideas about the danger of an enteral feeding tube, which is still considered to be invasive, dangerous and painful, contrary to the reality and the benefits it brings to the patient. This is because caregivers imagine and project an image of themselves in good health with a tube. But if it is explained to the patient that when you are ill with cancer and because of undernutrition, your cancer cannot be treated or not at the optimal doses, then patients are in favour of enteral nutrition. So we still need to develop this information and education approach with the healthcare teams, which is still insufficient.
Does the evolution of the population, pathologies and lifestyle influence the number of people affected by undernutrition?
I see what you mean, you are right. In Geneva, I helped analyse data from a questionnaire on the food intake of hospital patients and we showed that in ten years, between 2000 and 2010, there had been no change in the proportion of patients who did not eat enough in hospital. It was about two out of three patients. This may seem disappointing given that in the ten years, obviously, the hospital had put in place many measures to improve the food intake of patients and their coverage of nutritional needs, notably by prescribing more oral nutritional supplements, by increasing the number of dieticians, by improving the meals offered to patients in hospital… but this was explained at the time by the fact that the weight, the body mass index (which affects the calculation of needs) and the age of patients had increased. In addition, the fact that there were more chronic diseases meant that patients cases were potentially more severe. Finally, our conclusion was that, if we had not implemented these changes, the malnutrition would clearly have worsened. So all the measures that we were able to put in place were able to maintain the level at two-thirds. Whereas it could have been 80 or 90% if we hadn’t done anything.
I think that for undernutrition, it’s a bit the same. We’re going to have more and more undernourished patients. I’m thinking in particular of intensive care units and patients suffering from chronic diseases. A lot of progress has been made, we save lives, we extend the lives of patients who would have died 20 years ago more quickly, but they survive to the detriment of nutritional after-effects, a reduced muscle mass and therefore undernutrition and sarcopenia. So that’s where we have to be better. And then not to consider that the patient is cured because he survives the reanimation, no, the patient, at this moment, has no more muscles, he is exhausted and has a mediocre quality of life, so we must help them to find a normal life.
So I think that we are going to have a greater potential of undernourished patients in the future and this is also why colleagues are a little more concerned, because they know that the health of their patient depends on their nutritional state too.
In conclusion, an ageing population + chronic diseases + medical progress = more malnutrition.
Read about some of the levers that could be used to adapt and respond to patients’ needs in the second part of the article.