Healthcare professionals' perceptions of malnutrition management and oral nutritional supplement prescribing in the community: A qualitative study

The attitudes and knowledge of family physicians regarding malnutrition in the elderly: a call for action

BACKGROUND

Malnutrition in the elderly places a significant burden on healthcare, social, and aged-care systems, yet it often remains undiagnosed and untreated. This study aims to evaluate family physicians' knowledge and attitudes towards the diagnosis and treatment of malnutrition in the elderly.

METHODS

Based on a literature review, an online questionnaire was developed, comprised of seven knowledge-related items and eight attitude-related questions regarding malnutrition in elderly populations. We also assessed the feasibility of including two malnutrition screening questions in regular clinic visits for individuals aged ≥ 70 years.

RESULTS

Surveys were completed by 126 physicians (35% response rate), mean age 47.2 ± 12.6 years; 15.6 ± 12.5 years of practice; 67% females; and 92% board-certified family physicians. Moreover, 77.6% agreed that diagnosing malnutrition is important in patients with decreased appetite. Most respondents demonstrated knowledge of nutritional screening principles (63.5%) and recognized that even obese elderly individuals could be malnourished (83.2%). There was partial agreement (60%) that normal BMI values in the elderly differ from those in younger populations. Almost complete agreement was seen for incorporating two nutritional status questions in medical visits (91%), with physicians expressing willingness to receive training in malnutrition identification and screening tools. Despite challenges such as time constraints and limited knowledge, participants were open to conducting biannual malnutrition risk screening for elderly patients.

CONCLUSION

We recommend malnutrition screening in primary care followed by malnutrition diagnosis and referral of malnourished patients to the proper intervention.

Prevention and Treatment of Malnutrition in Older Adults Living in Long-Term Care or the Community: An Evidence-Based Nutrition Practice Guideline

Malnutrition in older adults can decrease quality of life and increase risk of morbidities and mortality. Accurate and timely identification of malnutrition, as well as subsequent implementation of effective interventions, are essential to decrease poor outcomes associated with malnutrition in older adults. The Academy of Nutrition and Dietetics Evidence Analysis Center conducted a systematic review of the literature to develop an evidence-based nutrition practice guideline for the prevention and treatment of malnutrition in older adults. The objective of this guideline was to provide evidence-based recommendations to identify, prevent, or treat protein-energy malnutrition in older adults (mean age ≥65 years) living in long-term care and community settings. This guideline provides 11 nutrition recommendations to inform shared decision making among dietitians, members of the health care team, family members or caregivers, and older adults living in long-term care or the community to prevent or treat malnutrition. Topics include dietitian effectiveness, nutrition assessment tools, oral nutrition supplements, food fortification, and home-delivered and congregate meals. Guideline implementation should include consideration of the importance of comprehensive individualized nutrition care for older adults. Future research is needed to address gaps that were identified related to the validity, reliability, and feasibility of nutrition assessment tools, as well as the effectiveness of dietitian interventions on outcomes of interest in older adults living in long-term care and the community.

Clinical nutrition in primary care: ESPEN position paper

Primary care healthcare professionals (PCHPs) are pivotal in managing chronic diseases and present a unique opportunity for nutrition-related disease prevention. However, the active involvement of PCHPs in nutritional care is limited, influenced by factors like insufficient education, lack of resources, and time constraints. In this position paper The European Society for Clinical Nutrition and Metabolism (ESPEN) promotes the active engagement of PCHPs in nutritional care. We emphasize the importance of early detection of malnutrition by screening and diagnosis, particularly in all individuals presenting with risk factors such as older age, chronic disease, post-acute disease conditions and after hospitalization for any cause. ESPEN proposes a strategic roadmap to empower PCHPs in clinical nutrition, focusing on education, tools, and multidisciplinary collaboration. The aim is to integrate nutrition into medical curricula, provide simple screening tools for primary care, and establish referral pathways to address malnutrition systematically. In conclusion, we urge for collaboration with PCHP organizations to raise awareness, enhance nutrition skills, facilitate dietitian accessibility, establish multidisciplinary teams, and promote referral pathways, thereby addressing the underestimated clinical challenge of malnutrition in primary care.

Evaluating the competency of community pharmacists in identifying and managing malnourished patients: A cross sectional survey

Background

Malnutrition is a global health issue that affects all age groups and regions. The integration of malnutrition screening into community pharmacy practices help address malnutrition. Community pharmacies, with their accessibility and reach, are well-suited to provide essential malnutrition screening services, contributing to improved public health outcomes.

Objective

The research objectives encompass evaluating community pharmacists' knowledge, screening proficiency, range of malnutrition services provided, and competence in identifying patients at risk of malnutrition.

Method

The study used a cross-sectional design to gather data from CPs in Kaduna State, Nigeria, using an online, self-administered, semi-structured questionnaire. Convenience sampling was used, and the data were evaluated using descriptive statistics.

Results

Eighty five percent of the 80 CPs who took the survey and provided responses practiced in urban areas. Approximately 37% and 18% of pharmacists, respectively, had a good and fair understanding of therapeutic nutrition. Additionally, while 33% of pharmacists provided nutritional advice in response to a prescription, 41% of them did so based on specific observations. Patients with severe dehydration (28%), infants and children with growth impairment (25%), and neonates with low birth weight (20%) were identified as high-risk. A little over 30% of survey participants thought patients should have both dietary and medical treatment. Additionally, 34% of pharmacists reported nutritional supplements had a positive impact on public health, while 28% believed they should be sold in pharmacies under pharmacist supervision.

Conclusion

Study findings revealed knowledge gaps in addressing malnutrition among CPs. While they play a significant role, improvements are needed in understanding therapeutic nutrition and providing advice. Identifying high-risk patients and recognizing the value of nutritional supplements can enhance public healthcare services and patient well-being.

Pharmacists' Perceptions on Nutritional Counseling of Oral Nutritional Supplements in the Community Pharmacy: An Exploratory Qualitative Study

Malnutrition has important health impacts, especially in the elderly. Oral nutritional supplements (ONS) are effective strategies to help balance the nutritional needs of malnourished persons. Multiple ONS are available at community pharmacies, enabling pharmacists to have the possibility to implement strategies for prevention and monitoring of malnourished patients. The aim of this study was to characterize the experience of community pharmacists with the counseling and follow-up of users of ONS. A sample of 19 pharmacists from 19 different community pharmacies were interviewed. Apart from dispensing ONS to support patients that are preparing for diagnostic tests, the most frequently mentioned clinical condition for ONS counseling was malnutrition and dysphagia. When pharmacists consider dispensing ONS, three themes emerge: patient care, related to counselling tailored ONS to each patient's needs; interprofessional collaboration, with a special focus in the collaboration with registered dietitians; and training and education on ONS, looking to improve their knowledge and skills in ONS counselling and follow-up. Future studies exploring new forms of interaction between pharmacists and dietitians in this context should be developed, aiming to determine the workflow of an interdisciplinary service addressing the needs of community dwelling malnourished patients.

Impact of malnutrition management e-learning module on GPs' knowledge: a pilot study

BACKGROUND

Malnutrition is underdiagnosed in primary care. GPs are key healthcare contacts for older adults at risk of protein-energy malnutrition; however, lack of knowledge and confidence in its diagnosis and treatment is often reported.

AIM

To evaluate the impact of a bespoke online education module on GP malnutrition knowledge and management.

DESIGN & SETTING

A prospective pre-post pilot study with 23 GPs and eight GP trainees in the Republic of Ireland.

METHOD

The module included units on the following: 'malnutrition definition, prevalence, and latest evidence'; 'identifying malnutrition in clinical practice'; 'food-first advice'; 'reviewing malnutrition'; and 'oral nutritional supplements'. Participant knowledge was measured using a multiple choice questionnaire (MCQ) before and after the module (n = 31), and 6 weeks following completion (n = 11). Case studies assessing identification and management of malnutrition were evaluated by a clinical specialist dietitian with expertise in managing malnutrition. Changes in assessment performance were calculated using paired t-tests. Acceptability was evaluated using a questionnaire.

RESULTS

Post-training, 97% of GPs increased MCQ scores from baseline (+25%, P<0.001), with the greatest improvement in 'identifying malnutrition in clinical practice' (mean increase 47%, P<0.001). Eleven GPs completed the 6-week MCQ with scores remaining significantly higher than baseline (mean increase 15%, P = 0.005); 'identifying malnutrition in clinical practice' remained the most highly scored (mean increase 40%, P<0.001). Seventeen GPs completed the case studies; 76% at baseline and 88% post-module correctly calculated malnutrition risk scores. Appropriate malnutrition management improved for 47% of GPs after module completion.

CONCLUSION

This e-learning module improved malnutrition knowledge, with good short-term retention in a small cohort. Development of online evidence-based nutrition education may improve GP nutrition care.

Reflections on recruiting healthcare professionals as research participants: Learning from the ONSPres Study

The involvement of healthcare professionals (HCPs) as research participants is essential to generate high quality evidence for enhancing health services and practice.  Research teams face many challenges in recruiting HCPs for research, and barriers and enablers for interdisciplinary research are not well described in the literature.  The Oral Nutritional Supplement Prescribing Malnutrition Research Study (ONSPres Study) examined malnutrition identification, management, and appropriate oral nutritional supplement prescribing in primary care in Ireland.  The ONSPres Study offers a unique view of recruiting HCPs for research because a range of disciplines were sought for participation in a mixed methods study.  The purpose of this open letter is to describe the experiences of recruitment and participation.  Sixteen general practitioners (GPs) were recruited to participate in one-to-one interviews, eighty health and social care professionals working in community care (including nurses, pharmacists, dietitians, physiotherapists, speech and language therapists, and occupational therapists) were recruited to take part in 12 focus groups, and 31 GPs and trainee GPs were recruited to participate in an education programme developed by the study team.   Strategies required to gain access and reach HCPs differed between disciplines.   Professional networks enhanced access to HCPs working in practice and recruitment was slower and more tailored when those networks were less available to the team.  An interest in malnutrition, to assist in research, to advance patient care, and the opportunity for learning were incentives for the participating HCPs.  Limitations in the diversity of the sample arose, with a bias towards female participants and GPs motivated by an interest in the topic.  It is recommended that study teams collaborate early with relevant HCP disciplines so they can contribute to recruitment planning at project concept and design stages.  To enhance and incentivise HCP participation in research, dedicated time and acknowledgement of participation as continuous professional development is proposed.

Advances in knowledge of screening practices and their use in clinical practice to prevent malnutrition

Malnutrition is common among older adults and is associated with a progressive decline in overall health and increased mortality. With a rapidly ageing population, the detection, prevention and management of malnutrition require urgent attention within health service planning and delivery. Routine screening for malnutrition among older adults in community settings, which addresses aetiological as well as phenotypic factors, is considered an important step for prevention and early intervention. The aim of this review is to summarise current malnutrition screening literature and highlight research that seeks to understand and address community-based approaches to malnutrition screening and management. Key healthcare professionals (HCPs) that encounter community-dwelling older adults include general practitioners (GPs), community-based nurses, community pharmacists and a range of other health and social care professionals including dietitians, physiotherapists, speech and language therapists, and occupational therapists. The key barriers to implementing screening in primary care include lack of knowledge about malnutrition among non-dietetic HCPs, lack of resources allocated to managing malnutrition, lack of access to dietetic services, and poor GP knowledge about oral nutritional supplement prescribing. In addition, older adults have poor insight into the clinical condition and the associated negative health implications. Investment in education among HCPs and public awareness is required, as well as accompanying resources to successfully implement malnutrition screening programmes for community-dwelling older adults.

Disparities in Oral Nutritional Supplement Usage and Dispensing Patterns across Primary Care in Ireland: ONSPres Project

When treating malnutrition, oral nutritional supplements (ONSs) are advised when optimising the diet is insufficient; however, ONS usage and user characteristics have not been previously analysed. A retrospective secondary analysis was performed on dispensed pharmacy claim data for 14,282 anonymised adult patients in primary care in Ireland in 2018. Patient sex, age, residential status, ONS volume (units) and ONS cost (EUR) were analysed. The categories of ‘Moderate’ (<75th centile), ‘High’ (75th–89th centile) and ‘Very High’ ONS users (≥90th centile) were created. The analyses among groups utilised t-tests, Mann–Whitney U tests and chi-squared tests. This cohort was 58.2% female, median age was 76 years, with 18.7% in residential care. The most frequently dispensed ONS type was very-high-energy sip feeds (45% of cohort). Younger males were dispensed more ONSs than females (<65 years: median units, 136 vs. 90; p < 0.01). Patients living independently were dispensed half the volume of those in residential care (112 vs. 240 units; p < 0.01). ‘Moderate’ ONS users were dispensed a yearly median of 84 ONS units (median cost, EUR 153), ‘High’ users were dispensed 420 units (EUR 806) and ‘Very High’ users 892 yearly units (EUR 2402; p < 0.01). Further analyses should focus on elucidating the reasons for high ONS usage in residential care patients and younger males.

Malnutrition: A Misunderstood Diagnosis by Primary Care Health Care Professionals and Community-Dwelling Older Adults in Ireland

BACKGROUND

Language and communication have an impact on how a clinical condition is treated and experienced, from both the health care professional (HCP) and patient perspective. Malnutrition is prevalent among community-dwelling older adults, yet perceptions of patient understanding of the term malnutrition to date remain underexplored.

OBJECTIVE

This qualitative study explored the use and perceptions of the term malnutrition among HCPs and older adults at risk of malnutrition.

DESIGN

Semi-structured interviews and focus groups were conducted with HCPs and older adults with a prescription for oral nutritional supplements (ONS) in the community, to explore perspectives.

PARTICIPANTS AND SETTING

HCPs with experience of working with older adults were recruited in primary care centers, general practitioner practices, community health organizations, and community pharmacies in County Dublin, Ireland, between 2018 and 2019. Older adults, aged ≥60 years, with a current or previous prescription for ONS were recruited from daycare centers. One-to-one interviews were conducted with general practitioners (n = 16) and patients (n = 13), and focus groups were conducted with other HCPs, including dietitians (n = 22), nurses (n = 22), pharmacists (n = 9), physiotherapists (n = 12), occupational therapists (n = 6), and speech and language therapists (n = 4).

DATA ANALYSIS

Data from interviews and focus groups were transcribed verbatim and analyzed using thematic analysis.

RESULTS

There was mutual agreement between HCPs and patients on the main theme, "malnutrition is a term to be avoided." There were three subthemes with varying input from the different HCP groups and patients: "Malnutrition is a term a patient doesn't want to hear"-malnutrition has negative connotations that imply neglect and stigma; "malnutrition is a clinical term which patients don't understand"-with perceptions that it is better to substitute the term with simpler motivating messages; and "lack of confidence identifying malnutrition"-expressed by non-dietetics HCPs who believed they had insufficient expertise on malnutrition to communicate effectively with patients.

CONCLUSIONS

HCPs and patients perceived negative connotations with the term malnutrition, and HCPs used alternatives in practice. Additional consultation with HCPs and patients is recommended to explore appropriate language for conveying health risks associated with malnutrition. Future research should also address how current communication challenges can be addressed as part of strategic management programs or interventions to prevent and treat malnutrition.