The Link Between State Hospital Regulations and Malnutrition

Malnutrition is a widespread issue impacting older adult health and healthcare costs. But it often goes undetected in hospital settings, even though studies estimate it affects a staggering 20%–50% of patients. Efforts by federal programs to increase malnutrition screening, assessment, diagnosis, and care planning, such as the Centers for Medicare & Medicaid Services (CMS) Global Malnutrition Composite Score quality measure for inpatient settings, are steps in the right direction. Yet there’s also a potential opportunity for local change through state hospital regulations. A new study investigated how malnutrition and nutrition are included in state hospital regulations.

Few State Hospital Regulations Mention Malnutrition

Researchers reviewed hospital regulations in all 50 states and in Washington DC, looking for mentions of nutrition and malnutrition, zeroing in on whether the terms appeared in a nutrition-care section of the regulations. This helped separate out nutrition mentions in hospital food service regulations from mentions related to the Nutrition Care Process.

The results revealed a stark reality: while nutrition was broadly mentioned (82% of state hospital regulations mentioned nutrition, mostly related to food service), only 49% mentioned nutrition in a dedicated Nutrition Care Process section. And there was no relation between nutrition mentions in a Nutrition Care Process section and a region of the country or states with large percentages of older adults.

More concerning was that malnutrition was mentioned minimally across all state hospital regulations. Just 2 state hospital regulations explicitly mentioned malnutrition in a Nutrition Care Process section—Nevada and Colorado (see map below). A third state’s regulations (Pennsylvania), mentioned malnutrition, but in the context of death notification. Researchers were unable to point to a specific reason for so few malnutrition mentions. Both Nevada and Colorado issued Malnutrition Awareness Week proclamations in 2022, but so did 29 other states. The 3 states (New Mexico, South Carolina and Utah) with the highest documented malnutrition death rates among older adults did not have any malnutrition mentions at all in their state hospital regulations.


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Opportunities for Improvement

The scarcity of malnutrition mentions in state hospital regulations presents an opportunity for policy change to enhance the quality of care for malnourished patients, particularly older adults. Several compelling reasons underline the significance of taking action:

  1. Increasing Older Adult Population: The older adult population is growing, and malnutrition risk increases with age. Deaths from malnutrition have doubled between 2018 and 2021, predominantly among older adults. Addressing malnutrition in state regulations could help pave the way for improved care for this demographic.
  2. Cost Savings: Malnutrition contributes to higher healthcare costs through increased hospitalizations and complications. Nutrition-focused quality improvement programs have been shown to result in significant cost savings.
  3. Health Equity: Malnutrition is closely linked to food insecurity and health equity. Incorporating malnutrition in state hospital regulations aligns with efforts to address health disparities and promote equitable care.
  4. Building on Federal Initiatives: The adoption of a malnutrition quality measure by CMS underscores the significance of malnutrition care. State regulations can complement and strengthen federal initiatives, further improving older adult care.
  5. Connecting with Community Nutrition Programs: Hospitals can play a pivotal role in identifying malnourished patients and connecting them with community nutrition programs and services. Including malnutrition in state regulations would facilitate a more seamless transition from hospital care to community support.

Malnutrition is a pressing issue affecting both older adults and healthcare systems. While federal policies are beginning to address this challenge, state hospital regulations offer an untapped avenue for improving malnutrition care. Recent research highlights the lack of malnutrition and nutrition care as part of state hospital regulations, providing a basis for future policymaking. Enhancing malnutrition-related provisions in state hospital regulations, particularly by integrating malnutrition into Nutrition Care Process regulations and outlining enforcement mechanisms, could significantly improve the identification and management of malnutrition among hospitalized individuals.

As malnutrition continues to impact older adult well-being and healthcare costs, addressing the issue through robust state regulations could prove pivotal in advancing malnutrition quality of care and patient outcomes across the nation.

Laura Borth, MS, RD, is a policy analyst for Defeat Malnutrition Today.

Photo credit: Shutterstock/sasirin pamai