Call to Action for the “Skeleton in the Hospital Closet”

by: Lindsey Hoggle, director, nutrition informatics, Academy of Nutrition and Dietetic

As a student completing dietetics training (in the late 1970s) in a large, academic teaching hospital on how best to support critically ill patients, there was a heavy cloud that hung over many of the patients I saw. Those clouds arose from a landmark article “The Skeleton in the Hospital Closet,” which was published in 1974 by Charles E. Butterworth, Jr.,,MD. It exposed the paradox of “physician-induced malnutrition as one of the most serious nutritional problems of our time.” This article was a tipping point for building an awareness of chronic disease-induced and injury-induced malnutrition in the U.S.

Dr. Butterworth lamented that it was indeed strange as to:

“…how frequently one sees the hospital stay prolonged and the patients suffering made worse by what we now recognize as frank mismanagement, if not downright neglect, of the patients nutritional health in our hospitals.”

This was a severe proclamation – particularly at a time that pre-dated extreme comments, which are now a part of our daily communication.

The landscape was much different during this time; the internet did not exist and would not surface for another 15 years after this shocking article. Social media was non-existent, e-mail was a new concept, and no e-mail lists were available to share proof of such research. Researching articles on malnutrition required a physical trip to the medical library, researching topics and locating references in a filing CardEx, then manually making copies on a copying machine that barely captured the full text of huge bound medical journals held in place while depositing nickels in the slot for copies.

I still remember my disbelief that malnutrition could be hiding in plain sight – until I experienced it from the standpoint of a registered dietitian nutritionist (RDN) charged with the nutrition care of patients. I was fortunate to work in some very progressive team-based academic teaching facilities – who were open to the need for nutritional support. After all, total parenteral nutrition (intravenous support of all necessary nutrients, typically bypassing the gut) had been term developed in the 1960s. Nutrition Support Teams, composed of physicians, nurses, pharmacists and nutritionists managed critical patients who could be sustained by increased oral nutrition supplements, enteral feedings and parenteral nutrition. Hospitals adhered to Joint Commission screening requirements – that patients be screened within 24 hours of admission and those identified at risk –assessed by an RDN. Heavy patient loads for RDNs precluded the lofty goal of creating nutrition interventions for every patient who needed it. Even with increased options for nutrition care, I often felt incapable of making the difference I hoped in the lives of many very sick patients.

Fast forward 40+ years - to 2017. Today we not only have an “Internet” but we are impatient when it does not instantaneously respond to our needs. E-mail, text-messaging, smart phones and all things digital – are a normal part of our personal and professional existence. We are on the cusp of near universal EHR use in non-federal US. Hospitals. Digital access to medical research is at the tips of our fingers and innovative efforts to dissolve the silos of personal health information is upon us. Collaboration of public-private-government projects to force “consumer centric” care are encouraging.

So what happened to the skeleton? It is still there- however collaborative efforts through the Academy of Nutrition and Dietetics have generated a powerful new call to action on malnutrition. One aspect of this effort includes patients and caregivers (patient advocate) and addresses documentation via four Malnutrition electronic Clinical Quality Measures. What does this mean?

  • Successful malnutrition intervention and care is possible, given patient-centered care. The management of malnutrition ripples across all care settings and should be a foundation of a Learning Health System.
  • A wonderful tipping point is upon us-- to address the burden of malnutrition in hospitalized patients. The team includes us all – Malnutrition basic knowledge is critical to making a difference in malnutrition.

HIMSS17 marks the seventh year for non-profit partnership between HIMSS and the Academy of Nutrition and Dietetics, and fourth year as an endorser. We appreciate the continued opportunity for improving nutrition care via health IT.


in health and IT meet.