Opportunities for Improving Health Equity Through Nutrition

By now, you have likely read statistics like these: every day, an estimated 15,000 hospital patients with malnutrition (or poor nutrition) go undiagnosed and more than 10% of U.S. households are food insecure. These conditions are known to impair health and are not experienced equitably—for example, malnutrition prevalence may be more than a third higher among Black adults than Whites. Older adults experience higher rates of malnutrition (which is often underdiagnosed) and associated poor outcomes in both clinical and community settings. Without appropriate identification and intervention, these conditions often worsen and many individuals (particularly older adults) are at greater risk for poor health outcomes.

Implementation of quality measurement can help inform solutions, as recently identified through interviews with seven Advisory Committee members of the Malnutrition Quality Improvement Initiative (MQii). The MQii is a multistakeholder initiative advancing evidence-based, high-quality and patient-driven care using clinical quality measures and a quality improvement toolkit to help identify and manage hospitalized adults who are malnourished or at risk for malnutrition. MQii leaders conducted a series of interviews to characterize existing challenges to improving malnutrition care and reducing food insecurity through the hospital setting, and to seek insights on how quality measurement can be used to address these issues and advance health equity.

Identifying the Problems

Advisory Committee members outlined existing challenges, including the little-known relationship between malnutrition and food insecurity, and disparities in access to healthy food and nutrition care.

Nutrition-related burdens on the healthcare system

Many nutrition-related deficiencies burden our healthcare system and create health inequities among U.S. populations. Advisory Committee members identified the most significant drivers as:

• Poor food availability and access, which can lead to disparities in diet quality and malnutrition and contribute to the obesity epidemic
• Insufficient nutrition knowledge among healthcare providers, which leads to insufficient ability to identify and treat poor nutrition
• Insufficient nutrition knowledge among the public, which may include limited knowledge of nutritious food and the impact of diet on health and/or lack of cooking skills

These deficiencies have several negative effects, including:

• Increasing the financial and personal burdens of chronic illness(es), which are more prevalent among older adults
• Contributing to poorer surgical outcomes stemming from baseline nutrition status
• Exacerbating overall poor health conditions among disadvantaged populations

The relationship between malnutrition and food insecurity

The connection between malnutrition and food insecurity is multidimensional and can have significant implications for the management of chronic diseases and anticipated health outcomes. There was consensus among the Advisory Committee members interviewed that malnutrition and food insecurity are directly related, but that this relationship is not well known nor understood by the many healthcare professionals lacking formal nutrition training, by policymakers or by the public.

While not all malnutrition can be addressed by alleviating food insecurity, malnutrition often results from the lack of adequate, affordable, nutritious food; therefore, these conditions should be addressed together. Malnutrition and food insecurity may be underrecognized in the U.S. because:

• Malnutrition may be perceived as solely an issue in developing countries, typically associated with starvation and inadequate food supplies
• In many neighborhoods, food insecurity and malnutrition do not necessarily stem from scarce food, but instead from a lack of access to fresh, high-quality, nutritious food
• Even among nutrition-educated providers, the link between malnutrition and food insecurity is not always well understood, which can lead to unsuccessful malnutrition interventions when the underlying cause of food insecurity is left unaddressed

Interviewees then identified multiple drivers of inequitable access to nutritious food and nutrition care, which must be addressed to support good health. Inequitable access to nutritious food is caused by:

• High food costs
• Neighborhood limitations (such as safety and walkability)
• Limited personal or public transportation
• Limited food literacy and/or traditional eating patterns not conducive to chronic conditions
• Limited access to and understanding of technology

Inequitable access to nutrition care is caused by:

• Insufficient availability of nutrition care (e.g., medical nutrition therapy from registered dietitian nutritionists (RDNs), lack of access to nutrition experts, and knowledge about nutrition among physicians
• Healthcare provider limitations in providing care focused on malnutrition (including pressures to address more acute conditions during the COVID-19 pandemic)
• Patients’ social risk factors and perceptions/concerns about the healthcare system

Finding the Solutions

Advisory Committee members noted that a variety of stakeholders need to be involved to improve the quality of nutrition care and integrate it into clinical and community settings. They suggested how to demonstrate to these stakeholders the significance of malnutrition and food insecurity issues. Stakeholders who should be engaged should include:

• Healthcare professionals including physicians, nurses, RDNs, and others providing direct patient care
• Social workers and community agencies who coordinate care and support broader social needs
• Hospital leadership/administrators who can implement policies/practices prioritizing nutrition management
• Patients needing nutrition care and family members/caregivers supporting patients’ needs at home

Interviewees suggested conveying several pieces of information to engage these stakeholders and convince them of the importance of improving nutrition care quality, including:

• Health outcome and cost savings data that show disparate outcomes between those who have and those who lack adequate access to high-quality, nutritious food
• Individual case studies or personal stories
• Current initiatives/policy proposals that recognize/address nutrition as key component of health equity

Further, the Advisory Committee interviewees identified several potential solutions, including strategies for increasing nutrition knowledge and for jointly addressing malnutrition and food insecurity in hospital and community settings.

Solutions for addressing lack of knowledge about nutrition and related disparities

Advisory Committee members highlighted several potential strategies to increase nutrition knowledge among healthcare providers and the public:

• Integrate nutrition education into existing structures such as residency programs, nursing staff meetings, etc.
• Support research and evidence generation to demonstrate how malnutrition and food insecurity lead to health inequities. To accomplish this, stakeholders can:
  • Publish individual case studies along with hard data to demonstrate to providers the scope and significance of the problems
  • Share this information widely among healthcare professionals and the general public
• Bring more people “under the tent” by including malnutrition, food insecurity, and quality measurement in any conversation about nutrition-related health inequities
• Leverage the extensive partnerships already established through the 312 members currently in the MQii Learning Collaborative to share lessons learned in addressing food insecurity and malnutrition from a clinical perspective

Solutions for jointly addressing malnutrition and food insecurity

Many MQii Advisory Committee members reported successfully implementing changes to better address the nutritional needs of the patients for whom they or colleagues in their organizations are providing care. Advisory Committee members recommended strategies and ideas to better structure clinical workflows so the issues of malnutrition and food insecurity can be addressed jointly in both hospital and community settings. In the hospital setting, such strategies include:

• Ensure interdisciplinary coordination (and ensure RDNs are included) and tailor processes to each team’s goals and available resources
• Incorporate food insecurity into existing clinical nutrition workflows, spanning screening, hospital-based interventions, incorporation into discharge plans, and appropriate referrals and follow-up
• Adjust internal hospital structures and operations (such as reporting structures that connect nutrition and nursing departments and innovative food service programs that complement clinical interventions)

Community-based solutions may follow discharge or meet needs regardless of hospitalizations; they include:

• Facilitate communication between clinical staff and community organizations, which begins with awareness of available resources in each setting
• Foster closer relationships between clinical setting, community services, and patients/families/caregivers to improve monitoring and coordination over time
• Extend clinical support to the community, such as through RDN home visits or telehealth appointments that help clinicians better understand patient home environments/social risk factors and tailor interventions accordingly

Solutions for reducing drivers of inequitable access to malnutrition care and nutritious food

While not explicitly asked during the interviews, Advisory Committee members touched upon potential solutions to address upstream determinants of inequitable access to malnutrition care and nutritious food. Advisory Committee members highlighted how measuring the quality of malnutrition care would:

• Promote a consistent framework to measure and report outcomes and compare malnutrition care among providers and across patient groups
• Better incentivize quality malnutrition care (such as if the Global Malnutrition Composite Score were adopted by the Centers for Medicare and Medicaid Services [CMS])
• Provide an opportunity to identify, track, and address food insecurity through the healthcare system (given its close relationship to malnutrition)

Future Opportunities

Overall, the Advisory Committee members provided valuable perspectives on what they see as the major drivers of nutrition-related disparities, gaps in clinical processes and areas for future improvement. Their insights on opportunities for improving health equity through quality care that is specific to addressing malnutrition and food insecurity risk can benefit not only the MQii leadership team and Learning Collaborative members to conduct more strategic, targeted and impactful work; they can also inform readers—whether patient advocates, healthcare providers, administrators policymakers, or others—to do the same for the older adult populations they serve. For more information about the MQii and why malnutrition matters, visit our website.

Christina Badaracco, MPH, RD, LDN, is a research scientist at Avalere Health in Washington, DC.