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Is there a case for advancing medical nutrition by tailoring care to individual needs?
Published on 8 January 2024
A staggering 24% of patients at hospital admission are found to be at risk for malnutrition, a factor linked to potential declines in physical and mental function, along with compromised clinical outcomes. This emphasises the vital role of medical nutrition (MN) in preventing further deterioration in clinical conditions and supporting recovery.
Over the years, MN products have become increasingly specialised to address unmet needs associated with specific diseases, such as Inflammatory Bowel Disease (IBD) and cancer. Yet, as patients become increasingly polymorbid, one must consider the sustainability of this condition-specific approach over the long term.
MN plays a vital role in enhancing patient care
Malnutrition, or undernutrition, can be defined as "a state resulting from lack of intake or uptake of nutrition that leads to altered body composition (decreased fat-free mass) and body cell mass1. The risk for malnutrition in hospitals is especially pronounced among patients over 70 years old, and those with conditions such as cancer, cardiac diseases, respiratory diseases, and gastrointestinal (GI) diseases, as illustrated in Figure 1. Consequently, these patients commonly grapple with diminished physical and mental function, resulting in impaired clinical outcomes. Indeed, disease-caused malnutrition is associated with heightened susceptibility to infections and comorbidities, delayed wound healing, impaired recovery, diminished quality of life and an increased likelihood of mortality. These consequences extend beyond the individual, impacting healthcare systems with higher costs, longer hospital stays and increased treatment needs. Therefore, addressing malnutrition within the healthcare landscape remains critical.
Dietary changes and MN are the main treatments for malnutrition, aiming to increase undernourished patients’ nutritional intake. Medical nutrition therapy, as defined by EU legislation, refers to “foods for special medical purposes”, i.e., “specially processed or formulated and intended for the dietary management of patients”3. This term encompasses oral nutritional supplements (ONS), enteral tube feeding (enteral nutrition (EN)) and parenteral (intravenous) nutrition (PN), further detailed in Figure 2. ONS is usually the preferred approach4, as it offers a non-invasive solution that can easily be initiated to enrich a patient’s diet. EN typically becomes a consideration if ONS proves insufficient or if patients face additional GI difficulties, such as dysphagia. PN tends to be reserved as a last resort for more critically ill patients who cannot receive nutrition orally and when EN is contraindicated, for instance, due to an impaired GI function or due to surgery. Initially, MN products were only indicated for general malnutrition and had simple formulas – high-calorie and/or high-protein solutions designed to provide a concentrated source of essential nutrients. These products were segmented by age group, product format (ONS vs EN) and flavours.
As an illustration, standard MN is recommended for Inflammatory Bowel Disease (IBD) due to the heightened risk of malnutrition associated with this condition. IBD encompasses Crohn’s Disease (CD) and Ulcerative Colitis, two chronic, relapsing, inflammatory disorders of the GI tract. This intestinal inflammation, combined with GI symptoms (e.g., severe diarrhoea, rectal bleeding) and certain medications (e.g., corticosteroids, sulfasalazine and methotrexate), can lead to complications that facilitate malnutrition. These complications include malabsorption, chronic blood and protein loss, and intestinal bacterial overgrowth. With a reported malnutrition prevalence ranging from 20% to 85%5,6, we estimate that 2.57m patients living with IBD worldwide may be malnourished as shown on Figure 3. Weight loss is particularly common in hospitalised IBD patients, reported in 70-80% of cases, and in 20-40% of CD outpatients7,8.
To effectively prevent and manage malnutrition in IBD patients, ESPEN guidelines recommend initiating a MN treatment with standard ONS9, such as Resource, Ensure or Fortimel. Patients often transition to standard EN, especially during the acute phase of CD or in remission to prevent relapse, as it has proven to be a highly effective therapy. Both ONS and EN standard solutions have demonstrated efficacy in addressing nutritional deficiencies despite symptoms (e.g., loss of appetite, nausea) and complications, thereby reducing the need for hospitalisation and surgery. Standard EN can even help heal the lining of the intestines, reduce swelling, and improve overall symptoms. Additionally, these have also been shown to prevent osteoporosis and paediatric development issues in these patients10.
MN products not only cater to specific conditions but also address symptoms beyond malnutrition
In the past 15 years, the MN market has shifted significantly towards greater product specialisation, a transition previously analysed by Sector & Segment11. Manufacturers have progressively tailored their products to therapeutic areas, leading to market segmentation by medical condition. In response to broader structural challenges and a commitment to a patient-centric approach, they introduced disease-specific innovations with refined ingredients that better target symptoms and meet clinical needs beyond malnutrition.
Expanding on the example of IBD, manufacturers commercialised specialised solutions that are more attuned to these patients’ needs, complementing existing standard products. They did so by focusing on ingredients designed to support the integrity of the intestinal mucosa, reduce inflammation, and facilitate digestion. This is particularly relevant for this disease, where malabsorption can hinder the breakdown and absorption of nutrients. To cite a few, Nutricia introduced an amino acid-based formula, Elemental 028 Extra, Nestlé Health Science (NHS) offers Modulen IBD, enriched with TGF-β2 (growth factor), while Abbott recommends their peptide-based Vital 1.5kcal, as described in Figure 4.
This new segmentation in the MN market created other dynamic submarkets, notably in Oncology, where highly specialised products address symptoms beyond malnutrition. This disease marked by uncontrollable cell growth and spreading to other parts of the body12 can have high nutritional needs. We estimate that 45% of cancer patients are malnourished, which translates to 8.68 million cancer patients worldwide. Malnutrition is particularly common with GI, lung and head and neck (H&N) cancers, as illustrated in Figure 5. Cancer-associated malnutrition can result from the tumour itself but also from anticancer therapies. It is diagnosed through weight loss and can be caused by a range of GI symptoms such as dysgeusia, appetite loss, mucositis and dysphagia. In severe cases, malnutrition can progress to cachexia, characterised by loss of lean body mass, muscle wasting and impaired immune, physical, and mental function13.
Manufacturers are thus innovating to counteract early symptoms such as dysgeusia, that is, an alteration in patients’ sense of taste. For instance, Nutricia and Nestlé Health Science launched products developed in collaboration with cancer patients, featuring unique flavours, as described in Figure 6. Resource Refresh comes in a Peach-Mint Tea flavour and does not contain ingredients that can cause a metallic aftertaste. Fortimel Compact Protein comes in various flavours, some with a refreshing menthol sensation and others with a warming sensation provided by spices.
More recently, these manufacturers have introduced nutrient-enhanced MN solutions specially formulated for oncology patients: Resource Support Plus, Fortimel Compact Protein Omega-3 (also known as Fortimel Omegacare). As the names suggest, these are high-protein solutions with added omega-3 to help manage inflammation and muscle cachexia resulting from the disease and its treatment. This trend towards tailoring MN to specific conditions marks a notable advancement in cancer care.
Meeting new challenges and unmet needs in MN requires even more specialisation
Nowadays, patients increasingly grapple with multiple chronic medical conditions simultaneously, a phenomenon known as polymorbidity. Studies estimate that ~1/3 of the global population grapple with more than one condition14,15. Elderly patients are the most concerned, with over half of adults aged 60 and above experiencing polymorbidity. As we age, the likelihood of developing age-related diseases increases, such as brain disorders, osteoarthritis and chronic respiratory conditions (e.g., COPD). Moreover, living with chronic conditions, such as Diabetes Mellitus, can lead to complications over time, particularly in cardiovascular health (e.g., hypertension, microvascular complications, Coronary Artery Disease, heart failure) and the development of Chronic Kidney Disease. Polymorbid patients are also at high risk of malnutrition among other GI disorders, with estimated prevalence rates of 40-50% within inpatients of tertiary centres16,17.
Unfortunately, current nutritional interventions are generic or, at best, designed for individual conditions, which presents a challenge for treating polymorbid patients. While nutritional guidelines acknowledge this issue, they recommend standard MN as a first-line treatment, as the field of specialised feeds for this patient group is still in its early stages. Condition-specific MN may not address the diverse needs of these patients either. For instance, an ONS designed for oncology patients may lack a low glycaemic index, making it unsuitable for those with Diabetes. Conversely, an ONS tailored for Diabetes patients may lack diverse flavours to address dysgeusia, or omega 3 for inflammation.
This could, therefore, underscore the need for innovations catering to multiple conditions simultaneously for optimal treatment. Currently, nutrient-enriched formulas, incorporating elements such as fibres or amino acids, show promise, but clinical research exploring the potential benefits of incorporating tailored formulas is still ongoing. However, it’s worth noting that disease-specific MN may face challenges in adoption due to its higher cost. Governments, typically, do not extend coverage beyond standard formulas, complicating the implementation of tailored nutrition within hospital settings. Moreover, patients may not be able to cover this extra cost if not covered by insurance, or may not perceive the benefits justifying the price of specialised MN.
In parallel, we observe other patient unmet needs requiring increased specialisation. Indeed, the demand for real food formulas and alternative proteins has surged in recent years, as patients grow wary of what they consume and avoid animal products for personal, religious, and increasingly for environmental reasons. MN manufacturers have responded, as evident during the 45th ESPEN Congress. Nearly all leading MN brands embraced plant-based products to remain competitive, launching a variety of vegan ONS containing pea or soy protein in Europe this year. As illustrated in Figure 7, examples include Nutricia’s Fortimel PlantBased, Nestlé Health Science’ Compleat range, Abbott’s Ensure Plant-Based products and Fresenius Kabi’s Fresubin Plant-Based. This new trend illustrates the importance of accommodating diverse dietary preferences that go beyond clinical needs.
Greater specialisation requires support for HCPs in selecting the best options for their patients
Once confined to addressing malnutrition, MN now plays a more multifaceted role in healthcare. A growing array of products targets symptoms beyond simple nutritional deficits, such as malabsorption, dysphagia and inflammation, and patient needs beyond the medical, such as dietary preferences. In addition, new challenges cross the recently established condition-specific segmentation of the market, as reflected by polymorbidity. Although further refinements in MN formulations to better target patients’ multiple needs seems like the right way forward, implementation barriers arise due to their higher cost. This raises the question: Is increased specialisation the most efficient solution?
Regardless, this rising complexity implies that HCPs need heightened awareness of MN products available, as they are responsible for selecting the right solution for each patient. HCPs’ understanding of the MN market greatly varies across medical specialities, institutions and countries. Whilst it is usually crucial to exchange with Dietitians as they oversee nutritional care and are well-informed about patient challenges, not all individuals concerned are routinely referred to this Specialist, particularly when their disease is not directly GI-specific. Consequently, manufacturers should also consider collaborating with HCPs who do not specialise in nutritional health but may be responsible for identifying and managing patients’ risk of malnutrition.
Through our experience in over 100 projects across 30 countries, we have seen these recurrent issues globally. There is a clear need for enhanced HCP education and support to ensure well-informed decision-making for optimal patient health and well-being. MN manufacturers thus have a renewed opportunity to provide services beyond simple product offerings. These may include Continuing Medical Education events, digital educational platforms, webinars, podcasts, practical tools and multi-disciplinary, collaborative masterclasses that foster learning and knowledge exchange with experts, such as Dietitians.
Sector & Segment can help you stay atop of trends and unmet needs to innovate and offer best-in-class services
Sector& Segment has extensive experience conducting in-depth market analysis to pinpoint, evaluate and benchmark the positioning, unique selling points, and comprehensive strategies of key competitors in MN. Our experts can apply our insights to tailor and refine your go-to-market strategy.
We can leverage our experience to help you:
Size and quantify the market opportunity
Analyse the market landscape and uncover avenues for differentiation
Identify trends and challenges in a market
Formulate comprehensive strategies for HCP engagement to enhance their awareness of nutritional concerns and optimise patient outreach
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