Clinical nutrition is a complex science that constantly changes in response to the changing burden of disease and new evidence (Gallegos, 2020). An issue often ‘hidden in plain sight’ is that patients in hospital are at risk of undernutrition and, unless proactive nutrition assessments, such as the Malnutrition Universal Screening Tool (MUST) and interventions are made, this unnoticed problem will continue to be associated with increased complications, infections, longer lengths of stay, higher costs (both at micro and macro levels), and higher mortality (Blaauw et al, 2019. Stratton, 2023).
Problems in low-income countries
For individuals and families in low-income countries (LIC) this is further compounded by chronic poverty and food insecurity (Siddiqui et al, 2020). As the World Food Programme (2024) has pointed out, in 2023, an estimated 333 million people experienced acute levels of food insecurity, with individuals not knowing where their next meal was coming from. In consequence, people admitted to hospital may already be undernourished and, from the limited literature available in sub-Saharan Africa, Miyoba et al (2018) identified that more than 60% of adult inpatients in Zambia were at nutritional risk.
In many countries there are few or no trained nutrition professionals (World Health Organization (WHO), 2018). This is partly due to a limited number of education programmes that cover clinical nutrition topics, issues with the registration and regulation of professionals and the availability of protocols for practice (Sodjinou et al, 2014; WHO, 2018; Chimera et al, 2020). The limited number of nutrition professionals can be overwhelmed with high patient referral numbers and the expectation to focus on international and national targets, for example in childhood malnutrition. They are therefore facing an almost impossible task with inpatient complexity increasing, life expectancy changing, and urban and rural lifestyles clashing.
The United Nations Sustainable Development Goal 3c identifies the importance of increasing health financing, recruitment, development, training, and retention of the healthcare workforce in LIC (United Nations, 2024). However, while a multidisciplinary approach is needed to recognise and respond to undernutrition, it is crucial that nutrition professionals have extended knowledge and skills to lead and effectively manage clinical nutrition strategies. In response to these, international health partnerships can be seen as a force for good, offering an opportunity for knowledge exchange and transfer through virtual and in-country peer support.
A Zambia-UK partnership
The Ministry of Health (Zambia) through Levy Mwanawasa Medical University, which is training clinical nutritionists, has partnered with Birmingham City University in the UK in an international health partnership with the aim of raising the profile of nutritionists as expert multidisciplinary team members and, through that, to enhance nutritional practice and competency. To do this, both education and practice need to be concurrently scaled up, thereby making sure that both move forward together. Activities will include capacity strengthening through a Centre of Excellence for Nutrition, which will be based at Levy Mwanawasa Medical University. This centre will oversee activities that include the establishment of a virtual community of practice for nutritionists/dietitians and will act as an ‘anchor’ for the harmonisation of national clinical nutrition protocols for practice.
For nutritionists in practice, peer support and mentorship will be provided by NHS dietitians in identified hospitals, as well as a series of ‘train the trainer’ courses. This development is only the first part of the clinical nutrition roadmap, because it is recognised that clinical nutrition is a relatively new specialty in Zambia and nutritionists are at varying stages of their careers. Therefore, it is essential that leadership skills are developed to allow nutritionists to develop such skills to become more visible in practice. In consequence, working with NHS dietitians who are working at different levels will allow for capacity strengthening and opportunities for a range of nutritionists in Zambia.
Patient care must always have a route for escalation and, in clinical nutrition, this includes referral to a nutritional professional. It is accepted that there is an overlap in knowledge and skills between different professional groups. For example, nurses may complete admission and ongoing routine ward-based screening tools for undernutrition, but they often refer on to other members of the multidisciplinary team, such as nutrition professionals. Evidence shows that strengthening the role of the nutritionist in the multidisciplinary team can improve patient-centred care, enhance learning regarding nutrition and dietary issues, and avert complications and costs due to early intervention and appropriate use of nutritional products (Hickson et al, 2023). Therefore, capacity strengthening of nutritional professionals is crucial, to allow for effective and comprehensive nutritional assessments and plans to be made, shared and implemented.
Nutrition professionals need other professional groups such as nurses to protect their patients who are at risk. However, for nutrition professionals there is a wider remit and opportunity to make a case at strategic level for improved clinical nutrition for hospitalised patients.
Making their voices heard
Highlighting the importance and need for clinical nutrition at all levels will result in policymakers hearing their voices, a first step in the process of change towards positive recognition. For as long as there is no recognition, appropriate education and training of nutritional professionals, nothing will change, and patients will remain at risk of not receiving appropriate nutritional support, leaving the issue still ‘hidden in plain sight’.
‘It is crucial that nutrition professionals have extended knowledge and skills to lead and effectively manage clinical nutrition strategies’