Malnutrition | Big Story


history of unplanned weight loss in the past three to six months (5-10%). Individuals who have had no oral intake for five days in the presence of acute disease are also at ‘high risk’ of malnutrition, this is less likely to be seen in the community. The management of this group is to commence intervention, often according to local policy.12 The management actions in the documents for


this vulnerable group were extremely variable, perhaps reflecting local resources available, including access to dietitians. Seven guidance documents recommended the use of food first alone in the management of this ‘high risk’ group. Other recommendations included OTC nutritional supplements (n=8) or ONS (n=6) prescribed in addition to the normal diet/food first approach. Referral to a dietitian was recommended in three documents. Where no improvement was achieved, escalation in treatment included ONS (n=12) or referral to a dietitian (n=5; 2 in addition to ONS).


‘At risk’ of malnutrition The majority of the documents that did not differentiate by degree of risk recommended a food first approach for this ‘at risk’ group (n=10). Three others included OTC nutritional supplements in addition to food first advice, and one advised food first plus prescribable ONS as first line action. However, within this 'at risk' group, nutrition needs can vary considerably. This variation in approach for a potentially


diverse group could result


mass index (BMI) and/or be losing weight unintentionally, whilst one has to bear in mind local resources, a long period without review could prevent further timely intervention where required in these vulnerable patients.


Outcomes and goal setting Only four documents made specific clear reference to goal setting or treating underlying conditions in addition to commencing oral nutrition support. Outcomes or goals identified tended to focus on weight and halting of weight loss. Review of progress relies on goal setting, to


establish whether actions are effective. Escalation of actions was indicated if ‘no improvement’ was noted, however, limited guidance was provided as to appropriate outcomes to gauge improvement. Only two guidance documents included patient related outcomes (e.g. ability to perform usual activities). Advice on what to review was not readily


available in the guidance documents, leaving this open to interpretation of the healthcare professional.


References to evidence Despite the drive to promote evidence based practice, a staggering 45 per cent of guidelines were unreferenced. Where references were included,


Figure 1: Guideline Authors in


‘medium risk’ groups receiving ONS, and ‘high risk’ groups receiving only food first advice. The review period for the combined risk group


was usually four weeks (range 1-12); where no improvement was observed the recommended escalation of treatment was most often the addition of ONS (n=10), OTC nutritional supplements (n=2) or referral to dietitian (n=2; 1 in addition to ONS prescription).


Referral to others Sixty per cent recommended referral to other healthcare professionals at some point in the management; in most cases this was initiated if no improvement was observed.


Review Periods for ‘medium risk’ and ‘high risk’ groups Review periods to evaluate the effectiveness of advice varied according to risk. For ‘medium risk’ four weeks was the most common period (79%), the remainder recommended review between one and four weeks (one recommended 12 weeks for free living individuals). For ‘high risk’ individuals there was


considerable variation in recommended review period (see Figure 2). Considering that ‘high risk’ individuals may have active disease, a low body


2% 24% 16% 8% 8% 42% Dietitians


Medicines Management Multidisciplinary Group Pharmacist


Not Documented Public Health


these were often as background information on malnutrition prevalence and NICE guidance on screening for malnutrition. Few references on malnutrition management were included.


Conclusion This descriptive review of oral nutrition support guidelines available from internet searches has highlighted inconsistenices in the management of malnourished patients in the community. The availability of information to enable practitioners to provide the most appropriate support for patients varies considerably and there is limited use of published evidence


to support


malnutrition management actions. Outcome measures, where included, focused


on weight. Patient related outcomes such as activities of daily living, independence, appetite and ability to eat, were lacking. This review of the


available guidance documents, combined with the lack of


awareness of GPs, highlights a need for an evidence based guide to support the identification and management of adult malnutrition in the community.


Figure 2: Review Periods - 'high risk' 5% 13% 13% 19% 42% 5% 3%


1 week 2 weeks 1-2 weeks 2-4 weeks 4 weeks


Up to 12 weeks Not specified


References: 1. National Institute for Health and Clinical Excellence (NICE) (2006). Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline 32. 2. Elia M and Russell CA (2009). Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition, led by BAPEN. 3. Stratton RJ, et al (2003). Disease-related malnutrition: an evidence-based approach to treatment. Oxford: CABI publishing. 4. Elia M, et al (2005). The cost of disease-related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. A report by BAPEN. Redditch, UK, BAPEN. 5. National Institute for Health and Clinical Excellence (NICE). Cost saving guidance. Accessed online: http://www.nice.org.uk/usingguidance/benefitsofimplementation/costsavingguidance.jsp (17.01.2012). 6. Stratton RJ, Elia M (2007). A review of reviews: A new look at the evidence for oral nutritional supplements in clinical practice. Clinical Nutrition Supplements; 2: 5-23. 7. Stratton, et al (2011). Systematic review and meta-analysis of the effects of oral nutritional supplements on hospital admissions. Clinical Nutrition Supplements; 6: 11: 16. 8. Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Research Reviews (2012); 11(2); 278-296 9. British Dietetic Association (BDA) (2009). A framework for screening for malnutrition. Accessed online: www.bda.uk.com (members section). 10. Cook WB, et al (2010). A national survey of General Practitioners understanding and awareness of malnutrition. Proc Nut Soc.; 69 (OCE7): E545. 11. Ashman K, et al (2011). Are the NICE clinical guidelines for nutrition support implemented in GP practices? CN Focus; 3(4): 26-28. 12. The ‘MUST’ Report (2003). Nutritional screening for adults: a multidisciplinary responsibility. Elia M, editor. Redditch, UK, BAPEN. 13. Stratton RJ, Elia M (2003). Encouraging appropriate, evidence-based use of oral nutritional supplements. Proc Nutr Soc.; 69(4): 477-487.


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