Skip to main content Accessibility help

Malnutrition in healthcare settings and the role of gastrostomy feeding

  • Matthew Kurien (a1) (a2), Jake Williams (a2) and David S. Sanders (a1) (a2)


Malnutrition can adversely affect physical and psychological function, influencing both morbidity and mortality. Despite the prevalence of malnutrition and its associated health and economic costs, malnutrition remains under-detected and under-treated in differing healthcare settings. For a subgroup of malnourished individuals, a gastrostomy (a feeding tube placed directly into the stomach) may be required to provide long-term nutritional support. In this review we explore the spectrum and consequences of malnutrition in differing healthcare settings. We then specifically review gastrostomies as a method of providing nutritional support. The review highlights the origins of gastrostomies, and discusses how endoscopic and radiological advances have culminated in an increased demand and placement of gastrostomy feeding tubes. Several studies have raised concerns about the benefits derived following this intervention and also about the patients selected to undergo this procedure. These studies are discussed in detail in this review, alongside suggestions for future research to help better delineate those who will benefit most from this intervention, and improve understanding about how gastrostomies influence nutritional outcomes.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Malnutrition in healthcare settings and the role of gastrostomy feeding
      Available formats

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Malnutrition in healthcare settings and the role of gastrostomy feeding
      Available formats

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Malnutrition in healthcare settings and the role of gastrostomy feeding
      Available formats


Corresponding author

* Corresponding author: Dr M. Kurien, email


Hide All
1. Stratton, RJ, Green, CJ & Elia, M (2003) Disease Related Malnutrition: an Evidence Based Approach to Treatment. Wallingford, UK: CABI Publishing.
2. Correia, MI, Perman, MI & Waitzberg, DL (2016) Hospital malnutrition in Latin America: a systematic review. Clin Nutr [Epublicaton ahead of print version].
3. FAO, IFAD and WFP (2015) The State of Food Insecurity in the World 2015. Meeting the 2015 international hunger targets: taking stock of uneven progress. Rome, FAO. (accessed 25th August 2016).
4. Saunders, J & Smith, T (2010) Malnutrition: causes and consequences. Clin Med (Lond) 10, 624627.
5. Stratton, RJ, King, CL, Stroud, MA et al. (2006) ‘Malnutrition Universal Screening Tool’ predicts mortality and length of hospital stay in acutely ill elderly. Br J Nutr 95, 325330.
6. Pressoir, M, Desne, S, Berchery, D et al. (2010) Prevalence, risk factors and clinical implications of malnutrition in French Comprehensive Cancer Centres. Br J Cancer 102, 966971.
7. Rasmussen, HH, Kondrup, J, Staun, M et al. (2004) Prevalence of patients at nutritional risk in Danish hospitals. Clin Nutr 23, 10091015.
8. McWhirter, JP & Pennington, CR (1994) Incidence and recognition of malnutrition in hospital. BMJ 308, 945948.
9. Ray, S, Laur, C & Golubic, R (2014) Malnutrition in healthcare institutions: a review of the prevalence of under-nutrition in hospitals and care homes since 1994 in England. Clin Nutr 33, 829835.
10. Elia, M (2015) The cost of malnutrition in England and potential cost savings from nutritional interventions (short version). (accessed 25 August 2016).
11. Schindler, K, Pernicka, E, Laviano, A et al. (2010) How nutritional risk is assessed and managed in European hospitals: a survey of 21,007 patients findings from the 2007–2008 cross-sectional nutritionDay survey. Clin Nutr 29, 552559.
12. Gout, BS, Barker, LA & Crowe, TC (2009) Malnutrition identification, diagnosis and dietetic referrals: are we doing a good enough job. Nutr Diet 66, 206211.
13. Agarwal, E, Ferguson, M, Banks, M et al. (2013) Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: results from the Nutrition Care Day Survey 2010. Clin Nutr 32, 737745.
14. Fang, S, Long, J, Tan, R et al. (2013) A multicentre assessment of malnutrition, nutritional risk, and application of nutritional support among hospitalized patients in Guangzhou hospitals. Asia Pac J Clin Nutr 22, 5459.
15. Rahman, A, Wu, T, Bricknell, R et al. (2015) Malnutrition matters in Canadian Hospitalized patients: malnutrition risk in hospitalized patients in a Tertiary Care Center using the Malnutrition Universal Screening Tool. Nutr Clin Pract 30, 709713.
16. Kopelman, P & Lennard-Jones, J (2002) Nutrition and patients: a doctor's responsibility. Clin Med (Lond) 2, 391394.
17. Department of Health and the Nutrition Summit Stakeholder Group (2007) Improving Nutritional Care: A Joint Action Plan from the Department of Health and Nutrition Summit Stakeholder Group. London: DH.
18. Beck, AM, Balknas, UN, Camilo, ME et al. (2002) Practices in relation to nutritional care and support – report from the Council of Europe. Clin Nutr 21, 351354.
19. NICE (2006) Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. (accessed 25 August 2016).
20. Barker, LA, Gout, BS & Crowe, TC (2011) Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health 8, 514527.
21. Elia, M & Russell, CA (eds); on behalf of BAPEN and collaborators (2003) The ‘MUST’ Report. Nutritional screening for adults: a multidisciplinary responsibility. Development and use of the ‘Malnutrition Universal Screening Tool’ (MUST) for adults. A report by the Malnutrition Advisory Group of the British Association for Parenteral and Enteral Nutrition.
22. Stratton, RJ, Hackston, A, Longmore, D et al. (2004) Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. Br J Nutr 92, 799808.
23. Poulia, KA, Klek, S, Doundoulakis, I et al. (2016) The two most popular malnutrition screening tools in the light of the new ESPEN consensus definition of the diagnostic criteria for malnutrition. Clin Nutr [Epublication ahead of print version].
24. Kondrup, J, Rasmussen, HH, Hamberg, O et al. (2003) Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr 22, 321336.
25. Kondrup, J, Allison, SP, Elia, M et al. (2003) ESPEN guidelines for nutrition screening 2002. Clin Nutr 22, 415421.
26. Guigoz, Y (2006) The Mini Nutritional Assessment (MNA) review of the literature–What does it tell us? J Nutr Health Aging 10, 466485; discussion 485–467.
27. Detsky, AS, McLaughlin, JR, Baker, JP et al. (1987) What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr 11, 813.
28. Kruizenga, HM, Seidell, JC, de Vet, HC et al. (2005) Development and validation of a hospital screening tool for malnutrition: the short nutritional assessment questionnaire (SNAQ). Clin Nutr 24, 7582.
29. Raslan, M, Gonzalez, MC, Dias, MC et al. (2010) Comparison of nutritional risk screening tools for predicting clinical outcomes in hospitalized patients. Nutrition 26, 721726.
30. van Bokhorst-de van der Schueren, MA, Guaitoli, PR, Jansma, EP et al. (2014) A systematic review of malnutrition screening tools for the nursing home setting. J Am Med Directors Assoc 15, 171184.
31. Elia, M (2009) The economics of malnutrition. Nestle Nutr Workshop Ser Clin Perform Programme 12, 2940.
32. Freijer, K, Tan, SS, Koopmanschap, MA et al. (2013) The economic costs of disease related malnutrition. Clin Nutr 32, 136141.
33. Elia, M (2015) The cost of malnutrition in England and potential cost savings from nutritional interventions (short version). (accessed 23 June 2016).
34. Muscaritoli, M, Krznaric, Z, Barazzoni, R et al. (2016) Effectiveness and efficacy of nutritional therapy – A cochrane systematic review. Clin Nutr [Epublication ahead of print version].
35. Kurien, M, Penny, H & Sanders, DS (2015) Impact of direct drug delivery via gastric access devices. Expert Opin Drug Delivery 12, 455463.
36. Buchman, AL, Moukarzel, AA, Bhuta, S et al. (1995) Parenteral nutrition is associated with intestinal morphologic and functional changes in humans. JPEN J Parenter Enteral Nutr 19, 453460.
37. Braunschweig, CL, Levy, P, Sheean, PM et al. (2001) Enteral compared with parenteral nutrition: a meta-analysis. Am J Clin Nutr 74, 534542.
38. Pearce, CB & Duncan, HD (2002) Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations. Postgrad Med J 78, 198204.
39. Kurien, M, McAlindon, ME, Westaby, D et al. (2010) Percutaneous endoscopic gastrostomy (PEG) feeding. BMJ 340, c2414.
40. Cunha, F (1946) Gastrostomy: its inception and evolution. Am J Surg 72, 610634.
41. Minard, G (2006) The history of surgically placed feeding tubes. Nutr Clin Pract 21, 626633.
42. Gauderer, MW, Ponsky, JL & Izant, RJ Jr (1980) Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 15, 872875.
43. Ponsky, JL (2011) The development of PEG: how it was. J Interv Gastroenterol 1, 8889.
44. Preshaw, RM (1981) A percutaneous method for inserting a feeding gastrostomy tube. Surg Gynecol Obstet 152, 658660.
45. Galaski, A, Peng, WW, Ellis, M et al. (2009) Gastrostomy tube placement by radiological versus endoscopic methods in an acute care setting: a retrospective review of frequency, indications, complications and outcomes. Can J Gastroenterol 23, 109114.
46. Ozmen, MN & Akhan, O (2002) Percutaneous radiologic gastrostomy. Eur J Radiol 43, 186195.
47. NCEPOD (2004) Scoping Our Practice: The 2004 Report of the National Confidential Enquiry into Patient Outcome and Death. London: NCEPOD.
48. Mitchell, SL, Teno, JM, Kiely, DK et al. (2009) The clinical course of advanced dementia. N Engl J Med 361, 15291538.
49. Jones, B (2008) Annual BANS report 2008: artificial nutrition support in the UK, 2000–2007. British artificial nutrition survey 2008. (accessed November 2016).
50. Malmgren, A, Hede, GW, Karlstrom, B et al. (2011) Indications for percutaneous endoscopic gastrostomy and survival in old adults. Food Nutr Res 55.
51. Martins, AS, Rezende, NA & Torres, HO (2012) Occurrence of complications and survival rates in elderly with neurological disorders undergoing enteral nutrition therapy. Rev Assoc Med Bras (1992) 58, 691697.
52. Sanders, DS, Carter, MJ, D'Silva, J et al. (2000) Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia. Am J Gastroenterol 95, 14721475.
53. Kurien, M, Leeds, JS, Delegge, MH et al. (2013) Mortality among patients who receive or defer gastrostomies. Clin Gastroenterol Hepatol 11, 14451450.
54. Sampson, EL, Candy, B & Jones, L (2009) Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev, CD007209.
55. Singh, S & Hamdy, S (2006) Dysphagia in stroke patients. Postgrad Med J 82, 383391.
56. Norton, B, Homer-Ward, M, Donnelly, MT et al. (1996) A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. BMJ 312, 1316.
57. Park, RH, Allison, MC, Lang, J et al. (1992) Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. BMJ 304, 14061409.
58. Dennis, MS, Lewis, SC & Warlow, C et al. (2005) Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Lancet 365, 764772.
59. Corry, J, Poon, W, McPhee, N et al. (2008) Randomized study of percutaneous endoscopic gastrostomy versus nasogastric tubes for enteral feeding in head and neck cancer patients treated with (chemo)radiation. J Med Imaging Radiat Oncol 52, 503510.
60. Nugent, B, Lewis, S & O'Sullivan, JM (2013) Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy. Cochrane Database Syst Rev, CD007904.
61. Britton, JE, Lipscomb, G, Mohr, PD et al. (1997) The use of percutaneous endoscopic gastrostomy (PEG) feeding tubes in patients with neurological disease. J Neurol 244, 431434.
62. Forbes, RB, Colville, S & Swingler, RJ (2004) Frequency, timing and outcome of gastrostomy tubes for amyotrophic lateral sclerosis/motor neurone disease--a record linkage study from the Scottish Motor Neurone Disease Register. J Neurol 251, 813817.
63. Mitsumoto, H, Davidson, M, Moore, D et al. (2003) Percutaneous endoscopic gastrostomy (PEG) in patients with ALS and bulbar dysfunction. Amyotroph Lateral Scler Other Motor Neuron Disord 4, 177185.
64. Mazzini, L, Corra, T, Zaccala, M et al. (1995) Percutaneous endoscopic gastrostomy and enteral nutrition in amyotrophic lateral sclerosis. J Neurol 242, 695698.
65. Katzberg, HD & Benatar, M (2011) Enteral tube feeding for amyotrophic lateral sclerosis/motor neuron disease. Cochrane Database Syst Rev, CD004030.
66. ProGas Study, G (2015) Gastrostomy in patients with amyotrophic lateral sclerosis (ProGas): a prospective cohort study. Lancet Neurol 14, 702709.
67. Perel, P, Yanagawa, T, Bunn, F et al. (2006) Nutritional support for head-injured patients. Cochrane Database Syst Rev, CD001530.
68. Kostadima, E, Kaditis, AG, Alexopoulos, EI et al. (2005) Early gastrostomy reduces the rate of ventilator-associated pneumonia in stroke or head injury patients. Eur Respir J 26, 106111.
69. Dahlseng, MO, Andersen, GL, Daga, M et al. (2012) Gastrostomy tube feeding of children with cerebral palsy: variation across six European countries. Dev Med Child Neurol 54, 938944.
70. Arrowsmith, F, Allen, J, Gaskin, K et al. (2010) The effect of gastrostomy tube feeding on body protein and bone mineralization in children with quadriplegic cerebral palsy. Dev Med Child Neurol 52, 10431047.
71. Sullivan, PB, Juszczak, E, Bachlet, AM et al. (2004) Impact of gastrostomy tube feeding on the quality of life of carers of children with cerebral palsy. Dev Med Child Neurol 46, 796800.
72. Sleigh, G, Sullivan, PB & Thomas, AG (2004) Gastrostomy feeding versus oral feeding alone for children with cerebral palsy. Cochrane Database Syst Rev, CD003943.
73. Kirby, DF, Delegge, MH & Fleming, CR (1995) American Gastroenterological Association technical review on tube feeding for enteral nutrition. Gastroenterology 108, 12821301.
74. Stroud, M, Duncan, H & Nightingale, J (2003) Guidelines for enteral feeding in adult hospital patients. Gut 52, Suppl. 7, vii1vii12.
75. Marks, JM & Ponsky, JL (1995) Access routes for enteral nutrition. Gastroenterologist 3, 130140.
76. Heaney, A & Tham, TC (2001) Percutaneous endoscopic gastrostomies: attitudes of general practitioners and how management may be improved. Br J Gen Pract 51, 128129.
77. Finucane, P, Aslan, SM & Duncan, D (1991) Percutaneous endoscopic gastrostomy in elderly patients. Postgrad Med J 67, 371373.
78. Nair, S, Hertan, H & Pitchumoni, CS (2000) Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia. Am J Gastroenterol 95, 133136.
79. Sanders, DS, Carter, MJ, D'Silva, J et al. (2002) Percutaneous endoscopic gastrostomy: a prospective audit of the impact of guidelines in two district general hospitals in the United Kingdom. Am J Gastroenterol 97, 22392245.
80. Abuksis, G, Mor, M, Plaut, S et al. (2004) Outcome of percutaneous endoscopic gastrostomy (PEG): comparison of two policies in a 4-year experience. Clin Nutr 23, 341346.
81. Monteleoni, C & Clark, E (2004) Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study. BMJ 329, 491494.
82. Rabeneck, L, McCullough, LB & Wray, NP (1997) Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Lancet 349, 496498.
83. Kurien, M, Westaby, D, Romaya, C et al. (2011) National survey evaluating service provision for percutaneous endoscopic gastrostomy within the UK. Scand J Gastroenterol 46, 15191524.
84. Kurien, M, White, S, Simpson, G et al. (2012) Managing patients with gastrostomy tubes in the community: can a dedicated enteral feed dietetic service reduce hospital readmissions? Eur J Clin Nutr 66, 757760.
85. Dinenage, S, Gower, M, Van Wyk, J et al. (2015) Development and evaluation of a home enteral nutrition team. Nutrients 7, 16071617.
86. Royal College of Physicians and British Society of Gastroenterology (2010) Oral feeding difficulties and dilemmas: a guide to practical care, particularly towards the end of life. London: Royal College of Physicians.
87. GMC (2010) Treatment and care towards the end of life: good practice in decision making. (accessed November 2016).
88. National Institute for Health and Clinical Excellence (2006) Dementia: supporting people with dementia and their carers in health and social care. (accessed November 2016).
89. Gilbert, J, Appleton, A, Jerrim, J et al. (2013) Assisted feeding for elderly inpatients. Clin Med 13, 324.
90. Watts, DT, Cassel, CK & Hickam, DH (1986) Nurses’ and physicians’ attitudes toward tube-feeding decisions in long-term care. J Am Geriatr Soc 34, 607611.


Malnutrition in healthcare settings and the role of gastrostomy feeding

  • Matthew Kurien (a1) (a2), Jake Williams (a2) and David S. Sanders (a1) (a2)


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed