Top-down and bottom-up approach of malnutrition
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Top-down and bottom-up approach of malnutrition leads to a decrease in malnutrition prevalence rates in all health care settings in the NetherlandsM. van Bokhorst - de van der Schueren, C. Jonkers - Schuitema, H. Kruizenga, A. Evers, E. van der Heijden, E. Leistra, J. Schilp, J. Meijers, R. Halfens, J. Schols, K. Joosten, G. Wanten, C. Mulder



  • LPZ (annual measurement of care problems)

    cross-sectional measurements of malnutrition across all health-care setting in the Netherlands, n ~30.000 patients per year

  • Multidisciplinary Steering Group

    (involving all disciplines as well as associations of specialists and hospital boards)

    lobbies the Ministry of Health to raise attention to the ongoing problem of disease related malnutrition in Dutch health care



  • Dutch Malnutrition Steering Group receives political endorsement and convinces Ministry of Health to support development of screening and treatment tools for hospitals, residential care and community

  • From 2006 the Ministry of Health is fully involved and funds the projects of the Dutch Malnutrition Steering Group from 2006-2012 (€ 1.5 billion)


The Dutch approach



Provision of instruments, website and half-products

Toolkits: (development, testing, implementation with the field)

Continuous internal and external audits and feedback on malnutrition prevalence, screening and treatment

  • Ministry of Health:

  • Financing

  • Nutrition report: The view on health and prevention

  • Mandatory screening and measurement of treatment

Data collection










Annual prevalence measurement

Screening instruments, toolkits, website

Training programmes

Mandatory screening

Mandatory reports on treatment




Nursing homes

per year

Home care

SNAQ, MUST, STRONGkids, growth analyzer


SNAQ 65+

60% participation

Experiments leading to best practices

Annual report to Healthcare Inspectorate

Annual report

Annual report

Annual report to Healthcare Insp.

Website per healthcare setting

Website per healthcare setting

Pocket booklet

Pocket booklet

Multidisciplinary guidelines

Multidisciplinary guidelines

Results at national level

Results at national level

Steady decrease in malnutrition prevalence rates

Key achievements

Key achievements

  • Mandatory screening and treatment in all health-care settings

  • Ongoing collection and feedback of malnutrition data

  • Malnutrition in main list of quality indicators in Dutch health care

  • Protein and energy goals for malnourished patients defined

  • Recognition of malnutrition as a healthcare problem as important as obesity

  • Malnutrition defined as one of the four topics in the National Safety Management System for all Dutch hospitals

  • (Risk of) malnutrition has become an official indication for reimbursement of medical nutrition in the basic health insurance

Key success factors

Key success factors

Key achievements:

  • LPZ (annual measurement of care problems) and Dutch Malnutrition Steering Group

  • Multidisciplinary approach

  • Involvement of Ministry of Health

  • Mandatory screening in all health care settings

  • Mandatory reporting on optimal treatment in hospitals

  • Interactive website and ready-to-use products

  • Toolkits to enhance implementation

  • Large numbers of training programmes and workshops

Future plans

Future plans

  • Annual measurement and further implementation of screening and treatment in all health care settings

  • Improvement of results

  • Sharing knowledge and experience in Europe and website in English

  • Strengthening the chain

  • A Ministry-funded “Malnutrition Knowledge Center”

  • Improvement in the basic education of (clinical) nutrition for doctors and nurses


Ellen van der Heijden, RD Hinke Kruizenga, PhD RD Anja Evers, RD LLM Chris Mulder, PhD MD

coordinator DMG project leader DMG project leader DMG president DMG

Cora Jonkers - Schuitema, RD Koen Joosten, PhD MD Geert Wanten, PhD MD Eva Leistra, MSc

secretary NESPEN & DMGNESPEN & DMG president NESPEN PhD student DMG

Ruud Halfens PhD RN Jos Schols, PhD MD Judith Meijers, PhD RN Janneke Schilp, MSc



... and all other researchers, dietitians, dietetic assistants, nurses, physicians, policy makers, patients, ...

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