Often Overlooked: Malnutrition with Overweight and Obesity

With all the media attention today on weight, the obesity epidemic, and medications to treat obesity, often overlooked is that individuals with overweight or obesity also can be malnourished.

This was the focus of an invited presentation by Katie Robinson, PhD, MPH, RDN, during the inaugural Nutrition Science Forum: “Addressing Malnutrition Across the Spectrum,” hosted by the Academy of Nutrition and Dietetics Foundation. The Abbott Nutrition Health Institute (ANHI) recently spoke with Dr. Robinson to learn more.

ANHI: How is malnutrition defined and why is it frequently overlooked in people with overweight or obesity?

Dr. Robinson: Lack of adequate intake of protein, vitamins and minerals are the primary types of malnutrition we are concerned about in individuals with overweight or obesity. Having a larger body size can mask when someone is malnourished and has lost muscle. So, if we don’t routinely conduct nutrition screening and assessment to identify the risk for malnutrition or document malnutrition, it is simply overlooked.

ANHI: Why is it a problem when malnutrition or malnutrition risk isn’t identified in people with overweight or obesity?

Dr. Robinson: We already know that up to 50% of all older adults are at risk for malnutrition or are malnourished, and that malnutrition is associated with poorer health outcomes and increased healthcare costs. We see similar concerns in people who have overweight or obesity and malnutrition risk. They have longer hospitalizations and higher mortality during hospital stays and increased odds of pressure injuries than their counterparts with obesity who are well-nourished.

ANHI: What are some of the factors contributing to malnutrition in people with obesity?

Dr. Robinson: Many of the factors leading to malnutrition in people with obesity are the same as those for individuals [in] other weight categories. These risk factors include social determinants of health such as food insecurity and social isolation as well as comorbidities or the presence of other chronic diseases or acute conditions. Lack of timely nutrition screening and assessment may exacerbate malnutrition. However, the issue of inadequate nutrition screening and assessment may be greater for individuals with overweight or obesity because nutrition screening tools typically rely on low body mass index (BMI) and/or unintentional weight loss. In addition, there can be weight bias and the inaccurate belief among some healthcare professionals that individuals with larger body size are not at risk for malnutrition.

“Having a larger body size can mask when someone is malnourished and has lost muscle.”

There are also some potential contributors to malnutrition that are unique to individuals with obesity. Obesity is a chronic disease that often includes chronic inflammation, metabolic abnormalities and altered energy utilization, all of which can increase malnutrition risk. Patients with obesity are recommended to lose weight to improve metabolic parameters, however, weight loss strategies vary and may not always be nutritionally adequate, especially if not supervised by a healthcare professional or Registered Dietitian Nutritionist (RDN).

Finally, in acute care settings, patients with overweight or obesity may be advised to significantly restrict food intake or not receive adequate protein and calories, potentially due to the bias that any weight loss is good weight loss and malnutrition is not a concern. These factors can contribute to malnutrition and also a related (but not identical) condition called sarcopenic obesity.

ANHI: You mentioned sarcopenic obesity, what is that and how is it a problem?

Dr. Robinson: Sarcopenia is the progressive loss of skeletal muscle and muscle strength. Risk for sarcopenia increases with age and can be impacted by nutrition and disease. Although diagnostic criteria and definitions vary, sarcopenic obesity is a type of obesity that occurs when there is elevated fat mass and low muscle mass or function. Unfortunately, it is quite common. In one study of Americans over age 60 years, 33.5% of women and 12.6% of men had both obesity and low lean mass.

There is also evidence that individuals who have a history of weight cycling (repeated intentional weight loss followed by weight regain) six or more times had at least five times greater risk for sarcopenia. Sarcopenia itself is associated with increased risks for falls, fractures, physical disability and death. Sarcopenic obesity is associated with prolonged hospital stay after surgery and longer time to return to regular activities, as well as increased odds of complications after surgery as well as higher hospital costs.

ANHI: Are there specific nutrition interventions for malnutrition and sarcopenia in people with overweight or obesity?

Dr. Robinson: Both physical activity and adequate protein in the diet are important for all older adults—including those with overweight or obesity—to help support muscle health. Unfortunately, 31%–50% of older adults (older than 50 years old) do not meet the recommended intake level for protein (0.8 g/kg/day). For people intentionally trying to lose weight, protein needs may be up to 50% greater than the generally recommended daily intake. One study found that a higher protein diet (greater than 25% of energy intake from protein) was associated with preservation of lean mass.

‘Incorporate food insecurity screening into medical care.’

Consultation with an RDN can help with individual recommendations for a high-protein diet. RDNs may recommend dietary strategies such as oral nutrition supplements to help provide protein and micronutrients to support meeting the nutrition needs of individuals pursuing intentional weight loss. The Academy of Nutrition and Dietetics offers a Find a Nutrition Expert website to help identify credentialed nutrition and dietetics practitioners by location, specialty, language, or insurance/payment options.

ANHI: What else can be done to help address malnutrition in people with overweight or obesity?

Dr. Robinson: In my talk during the Nutrition Science Forum, I identified six actions to help reduce malnutrition and sarcopenia in people with overweight and obesity:

  1. Screen, assess, diagnose, and intervene for malnutrition, regardless of body size or body mass index. The Centers for Medicare and Medicaid Services (CMS) has adopted the Global Malnutrition Composite Score (GMCS) as a quality measure to support improved access to malnutrition screening, assessment, diagnosis, and intervention in the hospital and this will help address malnutrition in people with overweight or obesity.
  2. Incorporate food insecurity screening into medical care. Food insecurity is when individuals do not have enough to eat and do not know where their next meal may be coming from. Food insecurity can contribute to increased risks for both obesity and malnutrition.
  3. Support muscle during intentional weight loss. A high protein diet individualized to meet needs and preferences along with regular physical activity may help limit muscle loss.
  4. Consider how stigma and bias may impact nutrition care. “A shift in mindset is urgently necessary to act on obesity as a public health crisis and ensure equitable access to evidence-based care.
  5. Support the Medical Nutrition Therapy (MNT) Act and the Treat and Reduce Obesity Act (TROA) to help increase older adults’ access to nutrition counseling and intensive behavioral therapy for obesity.

The Abbott Nutrition Health Institute is committed to being the world’s leading provider of therapeutic nutrition resources for everyone, at every stage of life. Today we support and empower half a million healthcare professionals and the millions of patients they serve.

Katie Robinson, PhD, MPH, RDN is the medical science liaison manager for the Nutrition Division of Abbott in Columbus, Ohio.

Photo credit: Shutterstock/LanaG