The clinical consequences of malnutr ition can be profound. Studies have repeatedly demonstrated that undetected and untreated malnutrition reduces muscle strength, contributes to frailty, increases falls risk, slows recovery from illness and surgery, and impairs psychosocial function, immune response and wound healing, all of which are associated with poorer clinical outcomes (Stratton et al, 2003; Bowling et al, 2010; Meijers et al, 2012; Morley et al, 2013; Gossier et al, 2016). The cost of malnutrition in the UK exceeds £23.5 billion per annum (Elia, 2015). At an individual level, it costs three times more, on average, to manage a malnourished patient than a non-malnourished individual (£7408 versus £2155) (Stratton et al, 2018). Therefore, action to detect, treat and prevent malnutrition are justified on both a clinical and cost basis.
Groups most at risk of malnutrition include those with chronic disease, progressive neurological disease, frailty, neurodisability, swallowing difficulties, acute illness and those with end of life/palliative care needs. Patients undergoing prehabilitation and rehabilitation, prior to and after surgery, are also at risk, and it is important that their nutritional status is optimised to prepare them for surgery and assist in their recovery. The needs of obese individuals, in whom a high body mass index can mask malnutrition and sarcopenia, should also be given special consideration.
A four-step approach to managing malnutrition
The Managing Adult Malnutrition in the Community panel has updated its guidance for community healthcare professionals. The updated guide reflects the latest evidence and best practice and is encouraging professionals to consider a four-step approach to the management of disease-related malnutrition:
- Step 1: Identification of malnutr ition: nutrition screening
- Step 2: Assessment: identifying the underlying cause of malnutrition
- Step 3: Management: identifying treatment goals and optimising nutritional intake
- Step 4: Monitoring the intervention
Developed by a multi-professional panel with an expertise and interest in malnutrition, the evidence-based document has been updated to incorporate the most up-to-date national and international guidance, as well as high-quality, peer-reviewed research. It emphasises the role of the multidisciplinary team in identifying and managing malnutrition, working alongside dietitians, and provides information for non-nutrition experts on actions to optimise dietary intake, along with appropriate prescribing of oral nutritional supplements (ONS) when required.
Three patient leaflets accompany the guidance document. The document and leaflets have been endorsed by ten key professional and patient organisations, including the Royal College of Nursing (RCN), the National Nurses Nutrition Group (NNNG), the Royal College of General Practitioners (RCGP), the Royal Pharmaceutical Society (RPS) and the Patients' Association.
This updated guidance aims to raise awareness amongst community healthcare professionals of how the underlying causes of malnutrition may be alleviated to break the repeated cycles of malnutrition, particularly amongst those with long-term conditions. Identifying the causes and symptoms that are interfering with a patient's ability to eat and drink and addressing those that can be reversed or modified needs to be an integral part of the patient's treatment plan. Such plans also need to consider the person's ability to act on the advice given and mitigate for any barriers, either clinical, practical or social, that may affect adherence to dietary advice and, if prescribed, the choice and type of oral nutritional supplements. We hope this guidance will assist professionals in taking action early, know when to refer on to a dietitian, and ultimately take us one step closer to optimising nutritional care for all our patients.
‘There are around 3 million people at any time in the UK who are malnourished or at risk of malnutrition’ says Liz Anderson, Lead Nurse for Nutrition at Buckinghamshire Healthcare NHS Trust and member of the Managing Adult in the Community panel. ‘Taking early action through screening and being aware of those at risk can prevent the escalating health and social care costs associated with a deteriorating state of nutrition. I hope that this four-step guidance will help community healthcare professionals to confidently take relevant actions whilst also identifying those patients who need to be referred on to a dietitian for additional support.’
Managing adult malnutrition in the community
The first edition of the Managing adult malnutrition in the community guidance was launched in 2012, and was subsequently updated in 2017 and 2021. Complementary guidelines include Managing malnutrition in COPD guidelines (2020) (www.malnutritionpathway.co.uk/copd) and A community healthcare professional guide to the nutritional management of patients during and after COVID-19 illness (2020) (www.malnutritionpathway.co.uk/library/covid19_hcpguide.pdf). The document is based on clinical experience and evidence, alongside accepted best practice. A full free copy of the guide can be downloaded at: www.malnutritionpathway.co.uk/library/managing_malnutrition.pdf.
As aforementioned, the guidance is accompanied by three colour-coded leaflets for use by patients and their carers, which have been updated to ensure they support the cultural diversity of patients. These are:
- Nutrition drinks (known as oral nutritional supplements): a red leaflet for those at high risk of malnutrition. This leaflet outlines to patients why they have been prescribed oral nutritional supplements and offers them general advice on getting the most from their supplements—for example, advice on cooking with supplements and storage
- Your guide to making the most of your food: a yellow leaflet for those at medium risk of malnutrition, which provides some simple ideas for patients on how they can get the most nutrition from the food they are eating
- Eating well: a green leaflet for those at low risk of malnutrition, which gives patients advice on how to eat well and keep as healthy as possible.
All three leaflets can be downloaded for free at www.malnutritionpathway.co.uk/leaflets-patients-and-carers.
Key points
- The updated ‘Managing Adult Malnutrition in the Community’ guide is based on the latest evidence, including national and international guidance, and clinical practice
- The document and complementary patient leaflets have been produced by a multidisciplinary panel and are endorsed by ten professional and patient associations
- Action to detect, treat and prevent malnutrition are justified on both a clinical and cost basis
- Professionals should consider a four-step approach to the management of disease-related malnutrition, which includes screening, assessment, management plan and monitoring.