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Treatment in general practice Module 179: July 2012
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Malnutrition
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Identifying malnutrition among people living independently in the community presents a great
challenge. Incorporating screening into clinical practice can help
(This module was facilitated by Niamh Maher)
In the current healthcare environment, there is pressure to promptly identify conditions, and to treat them in an
ethical and clinically effective way, using limited resources.
This applies to the treatment of disease-related malnutrition
(DRM), a condition that is widespread in hospitals, community healthcare settings and in free-living older people.1
DRM is detrimental physiologically and clinically,
impairing quality of life and delaying recovery from illness. Considering the widespread prevalence and adverse
consequences of malnutrition, a condition that is largely
treatable, prompt identification is required, followed by the
most appropriate, effective and ethical treatment.2
Pathogenesis of malnutrition
Malnutrition can be defined as a nutrition imbalance,
arising from a deficiency or excess of energy, protein and
other nutrients, causing measurable adverse effects on
tissue/body form, function and clinical outcome.3,4 This
definition encompasses overnutrition and obesity as well as
undernutrition, but in the context of this article, malnutrition will be synonymous with undernutrition.
The National Institute for Health and Clinical Excellence
(NICE) defines malnutrition according to one or more of the
following parameters5:
• BMI < 18kg/m2
• Unintentional weight loss > 10% within the previous
three to six months
• B MI < 20kg/m 2 and unintentional weight loss > 5%
within the previous three to six months.
The International Consensus Guideline Committee on
Malnutrition Syndromes define malnutrition as being
starvation-related or disease-related, acknowledging that
varying degrees of acute or chronic inflammation are key
contributing factors in the pathophysiology of malnutrition
that is associated with disease or injury.6
Prevalence
Malnutrition is a common but frequently unrecognised
problem, the incidence and prevalence of which are dif-
DL malnutrition 15/6 1
ficult to determine, but it has been estimated to affect over
20 million people in Europe.7 Based on age-adjusted comparisons with large-scale UK data, it is estimated that at
least 140,000 Irish adults are affected, representing about
3% of the population. This is lower than in the UK (5%)
and other countries in Europe, reflecting Ireland’s younger
population. Only 11% of our population is aged 65 years
or over, compared with 16% in the UK and 17.2% within
the EU.8
Approximately 93% of all those who are malnourished,
or at risk of malnutrition, are living in the community and
a further 5% are in long-term care. In those aged 65 years
or more, prevalence of malnutrition has been found to be
between 10-15%, with the oldest subjects at greatest risk.9
This estimate is based on comparisons with studies in UK
and Europe, since no survey has been conducted among
older free-living people in Ireland.
The prevalence of DRM among residents in long-term care
is higher at 32%, based on results from 12 Irish nursing
homes that participated in the BAPEN Nutrition Screening
Week 2010.1
Who is most at risk?
Those considered most at risk of malnutrition are older
people, particularly those who are hospitalised or living
in nursing homes, people on low incomes or those who
are socially isolated. Also at higher risk are those who are
recovering from a serious illness or who have chronic conditions, such as stroke, upper GI malignancies or progressive
neurological disease, particularly if it affects their ability
to eat.10
Causes of malnutrition
The main causes of DRM are impaired intake, impaired
ingestion and absorption, altered metabolic nutrient
requirements and excess nutrient losses (see Table 1). Psychosocial factors such as social isolation, bereavement and
poverty may also have significant effects on dietary intake
in some groups. The relative importance of each problem
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DISTANCE LEARNING Malnutrition
Table 1
Factors contributing to disease-related malnutrition5
Problem
Impaired intake
Impaired digestion and/or absorption
Altered nutritional requirements
Excess nutrient requirements
Cause
• Poor appetite: illness; pain/ nausea when eating; depression/ anxiety; food aversion;
medication; drug addiction
• Inability to eat: diminished consciousness; confusion; weakness or arthritis in arms
or hands; Dysphagia; vomiting; painful mouth conditions; poor oral hygiene or dentition; restrictions imposed by surgery or investigations
• Lack of food: poverty, poor quality diet at home, in hospital or in care homes; problems with shopping or cooking
• Medical or surgical problems effecting stomach, intestine, pancreas and liver
• Increased or changed metabolic demands related to illness, surgery, organ dysfunction, or treatment
• Gastrointestinal losses: vomiting; diarrhoea; fistulae; stomas; losses from nasogastric tube and other drains
• Other losses: skin exudates from burns
varies and multiple factors often occur simultaneously.5 In
addition, inflammation is being increasingly identified as
an important underlying factor that increases the risk of
malnutrition, and may contribute to suboptimal response to
nutrition intervention and increased mortality.6
The onset of nutritional problems is often gradual and
therefore hard to detect. However, features found in the
history and examination may help identify those at risk.
People can present with a variety of problems that may be
vague or non-specific. Patients may report reduced appetite
and energy and have altered taste sensation and changes
to their normal bowel habit. Clinical features that may suggest undernourishment include low body weight, fragile
skin, wasted muscles, recurrent infections and impaired
wound healing.5
Consequences of malnutrition
The consequences of DRM are serious for the patient and
costly for the health service.10 Malnutrition doubles the risk
of mortality in hospital patients overall and triples mortality
in elderly patients. Malnourished patients are twice as likely
to develop pressure ulcers when compared with well-nourished patients. Their risk of infection is more than three
times higher and they are more likely to develop pneumonia. In addition, prolonged inadequate protein intake may
exacerbate sarcopaenia, increasing the risk of falls and fractures. Older women with weight loss have increased rate of
hip-bone loss and a two-fold increased risk of subsequent
hip fracture.11-13
In the community, malnourished patients have 65% more
GP visits and have significantly more hospital readmissions
(+85%). Their average length of stay in hospital is 30-40%
longer when compared with well-nourished patients, with
hospital costs increasing even more when nutritional status
deteriorates further during admission. Loss of functional
status in DRM increases the likelihood of discharge to longterm care facilities and malnourished elderly patients are
three times more likely to die within six months of discharge
from hospital.9,14
The annual cost of malnutrition in Europe is at least e120
billion.7 In Ireland alone, the healthcare costs of treating
malnourished patients have been estimated at €1.4 bil-
lion annually, representing over 10% of total public health
expenditure: double the cost of obesity and its comorbidities.8, 15 This figure is likely to rise as our population ages.
The healthcare cost of managing malnourished patients
is twice that of well-nourished patients.10 The potential cost
savings associated with effective nutritional intervention in
the management of DRM must be considered. Improving
systematic screening, assessment and treatment of malnourished patients would lead to reduced complications
such as secondary chest infections, pressure ulcers, wound
abscesses and cardiac failure.
Conservative estimates of reduced admissions and
reduced length of stay for admitted patients, reduced
demand for GP and outpatient appointments, indicate significant savings of approximately £28,500 per £100,000
spent on healthcare costs.16
Identifying malnutrition risk
It is necessary to identify those individuals that are
malnourished, or at risk of malnutrition, who are likely to
benefit from nutrition support. ‘Thinness’ is not a reliable
indicator of malnutrition.
Overweight and obese patients can undergo very significant nutritional depletion before appearing undernourished,
yet have clinically relevant malnutrition. This is because the
average adult in Ireland has a BMI in excess of 27kg/m2
and would need to lose > 25% of body weight to fall below
the 20kg/m2 threshold for underweight, by which time
nutritional depletion is severe and difficult to treat.17
Objective classification of a patient’s risk of DRM, using a
validated screening tool, can assist clinical decision-making
and facilitate earlier intervention and better outcome.
Nutrition screening
Nutrition screening has been defined by the American
Society for Parenteral and Enteral Nutrition (ASPEN) as:
“a process to identify an individual who is malnourished
or who is at risk for malnutrition to determine if a detailed
nutrition assessment is indicated”.18
Where risk is identified, the action required will depend
on the degree of risk. First-line advice on dietary changes
may suffice for those at lower risk, whereas those at high-
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DISTANCE LEARNING Malnutrition
Table 2
Ways to optimise oral nutrition intake
PROBLEM
SOLUTION
Loss of appetite
• Check medications: alter where possible to minimise adverse effects
• Encourage ‘little and often’ – three small meals with regular in-between snacks of energy-rich, high-protein
foods
• Encourage people to eat every two to three hours
• Maximise times of better appetite, eg. if hungry in the morning suggest a cooked breakfast – eggs, baked
beans, cheese on toast
• Serve meals and snacks that are appealing in size and appearance – large meals can be off putting, use
small plates and maximise the ‘eye appeal’ of the food
• Food has to be eaten to be of benefit – encourage the patient to select favourite foods that can be eaten at
any time, eg. cereal for supper, soup for breakfast
• Drinks can lessen appetite – suggest that drinks are taken after meals rather than before and during a meal
• Find ways to stimulate the appetite – a short walk before meals can be helpful
• Consider meal settings – make meal times enjoyable and avoid interruptions or rushing during meals
Chewing problems
• Encourage adequate dental and mouth care
• Try soft foods that require little chewing
Swallowing difficulties
• Consider referral for speech and language therapy assessment
• Modify the consistency of foods as appropriate
Fatigue or difficulty
obtaining or preparing food
• Use convenience foods: frozen meals, canned items (soup, fruit, beans, fish) ready desserts (custard,
yoghurt, rice pudding), snack bars, breakfast cereals
• Enlist family and carer support, consider Meals on Wheels
• Make the most of good days: prepare snacks and meals to eat later or to store in the freezer
• Fortify food with extra fats and sugar – add oil, butter, margarine, cream, cheese, dressings, sauces, sugar,
honey and spreads to meals and snacks to boost energy intake
Mobility problems
• Consider assessment by a physiotherapist or occupational therapist
• Ensure shopping and food preparation assistance is available
Chronic pain
• Find and treat cause where possible – check analgesic use
Social isolation, depression
• Meals on Wheels; family, friends and social services
• Check medication use, consider counselling
est risk should be referred to a dietitian for a more detailed
nutrition assessment.
Incorporating screening into clinical practice entails routine measurement and recording of weight, height and BMI.
In general practice, this should be done for new patients
registering with a practice and those over 75 years; for
those having routine annual health assessments; in vulnerable groups; and for those where there is clinical concern
(eg. those who are frail and elderly, the poor and socially
isolated, those with severe diseases and disabilities).
Screening should be repeated at intervals, usually where
there is cause for concern, or at least every three months
for those with identified risk.5, 18
Screening programmes that result in at-risk patients being
treated earlier with nutritional support have been shown
to be highly cost-effective, providing benefits for patients
and the healthcare system. Despite this, screening is not
routinely conducted in the majority of healthcare settings,
nor is there a national strategy in place to manage DRM
patients once identified.
Identifying malnutrition among people living independently in the community presents a great challenge, since
there is no single point of reference, eg. on admission to
hospital or nursing home, at which to screen.
Where a patient is identified as being at high risk of
malnutrition, there can be limited access to community
nutrition and dietetic services in some areas, due to lack
of resourcing.
Screening tools
The NICE guidelines recommend the Malnutrition Universal Screening Tool (MUST) which was developed by
the British Association of Parenteral and Enteral Nutrition (BAPEN).5 This is simple, valid and reliable, and is
suitable for practical use by a range of healthcare workers
operating in different healthcare settings.19 MUST involves
assessment of weight status (BMI), change in weight, and
the presence of an acute disease resulting in no dietary
intake for more than five days (or likely to result in no dietary intake for more than five days). All three components
can independently influence clinical outcome.
In situations where weight and height cannot be measured,
self-reported measurements, other surrogate measurements
(such as ulna length or mid-upper arm circumference) and
clinical judgement can be used to reliably estimate risk of
malnutrition.
The tool categorises subjects into low, medium or high
risk of malnutrition. It provides guidance on the interpretation of measurements, and suggests appropriate care plans,
which can be modified to take into account local policies
and resources. It has very good to excellent reproducibility
when the same patients are assessed by different staff in
different healthcare settings (hospital, GP surgery and care
home). A variety of aids have been developed to facilitate
implementation of nutritional screening, eg. the MUST
toolkit is available to download from the BAPEN website
(www.bapen.org.uk/musttoolkit.html).
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DISTANCE LEARNING Malnutrition
Nutrition intervention
A nutrition assessment provides the basis for a nutrition
intervention.18 For some patients dietary modifications
can produce satisfactory improvements in malnutrition
outcomes, whereas others may require additional oral
nutritional supplements (ONS) to achieve an adequate
nutritional intake.20
Food first
The first step in addressing malnutrition should always
be to maximise an individual’s nutritional intake from regular food and drink, often termed ‘food first’. The food first
approach includes increasing the frequency of eating, maximising the nutrient and energy density of food and drink
and fortifying food with the addition of fats and sugars (see
Table 2).
Patients who are at very high risk of malnutrition or for
whom first-line dietary measures are not sufficient, oral
nutritional supplements should be considered in combination with the food first approach.5
The role of oral nutritional supplements
Oral nutritional supplements (ONS) are nutritionally complete liquid supplements that contain a mix of
macro- and micronutrients. ONS are designed to improve
nutritional intake and play a key role in the management
of malnutrition.
Studies show ONS to be highly effective when used in
malnourished or at-risk patients in improving nutritional
intake, attenuating or reversing weight loss, reducing complications, reducing length of hospital stay and reducing
mortality.2 ONS are consistently effective in improving total
energy and nutrient intake without reducing appetite or
food intake.2
Improving ONS compliance
The evidence on compliance varies. A common perception
is that compliance with ONS is poor, potentially attributable to palatability, duration of ONS, poor understanding of
the importance of ONS in health outcomes and absence of
adequate follow-up.
An Irish study, in which patients that were already prescribed ONS by their GP were interviewed by a community
dietitian, found that almost half of the patients were
reported not to be compliant with their ONS prescriptions.21
On the other hand, a recent systematic review suggests that
in fact compliance with ONS is good, especially with higher
energy-density ONS. Overall, mean compliance with ONS
was significantly higher in a community setting (81%).22
An understanding of the relationship between nutritional status and health outcomes, as well as setting target
weights and educating the patients and carers on the role of
ONS in achieving this target, may help improve compliance
and lead to an improvement in nutritional status.23
The cost-effectiveness of ONS in a community setting
has been a cause for concern in the past. According to the
Barry report, in 2007, ONS accounted for approximately
60% of the expenditure on clinical nutrition products.24
Some audits have shown that ONS may be initiated inappropriately or continued unnecessarily or without review in
general practice. 25, 26 ,27
Community dietetics intervention in Ireland has been
Table 3
Managing malnutrition in
general practice
• Use a validated screening tool, such as ‘MUST’ to
identify malnutrition or risk of malnutrition. Remember
‘MUST’ is available online for ease of access
• Screen all patients when they register with the practice
or existing patients that fall into the higher risk groups
• Implement appropriate nutritional treatment as part of
care plan and refer to the community dietetic service if
appropriate
• Consider ONS as part of the care plan for the treatment
of malnutrition:
· ONS can be used if an increase in energy, protein and
micronutrient intakes are required. ONS tend not to
suppress appetite or voluntary food intake, and are
particularly effective in acutely ill, elderly and postsurgical patients
· ONS can be used to attenuate weight loss in the
acutely ill or aid weight gain in the chronically ill.
Weight gain > 2kg, is associated with improvements in
function in the chronically ill
· Consider high-protein ONS to reduce the risk of
developing pressure ulcers in high-risk groups (frail
elderly, hip fracture, poor mobility) and to help improve
outcome in hip fracture patients
• The goal of treatment should be identified for the
individual at the start of treatment, with specific weight
targets. Thereafter, regular and frequent monitoring of
patients receiving ONS should be undertaken:
· Assess ONS acceptability
· Monitor ONS effectiveness by monitoring the patient’s
progress towards a treatment goal
· Encourage compliance, assess if still appropriate/ required
· Monitor changes in clinical and nutritional status
shown to improve ONS prescribing practices by healthcare
professionals, in accordance with best practice guidelines,
without increasing expenditure on ONS during the year after
intervention.21 See Table 3 for practical recommendations
for managing malnutrition.The goal for treatment should be
set at the beginning with specific weight targets.
A recent Irish study points to accumulating evidence of
cost savings associated with timely nutritional intervention
in both hospital and community settings. Despite the estimated annual care cost of e1.4 billion for these patients,
little attention has been given to this area. 28
Role of the dietitian
Dietitians are uniquely skilled to facilitate training of
other key health professionals on nutrition screening. Where
a patient is identified as being at high risk of malnutrition,
a dietitian is best qualified to provide a comprehensive
nutritional assessment and nutrition care plan, providing
relevant dietary advice and recommending the use of oral
nutritional supplements when appropriate.
Structured monitoring of treatment outcomes and compliance allows for ONS prescriptions to be revised or
discontinued in a timely manner.
Niamh Maher is a senior community dietitian with
HSE Dublin/North East
References on request
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