Clinical briefing: Malnutrition

The focus on excessive consumption and its effects on health often overshadow undernutrition, which remains surprisingly common in the UK in the midst of plenty...

Key facts

  • 11 per cent of people presenting at GP practices are undernourished
  • Undernourished people are at increased risk of falls because of greater frailty and poorer muscle strength
  • Oral nutritional supplements can complement and support dietary strategies


The recently published ‘Guide to managing adult malnutrition in the community’ (malnutritionpathway.co.uk) notes that, in the UK at any time, more than 3 million people are malnourished or are at risk of malnutrition. Indeed, 11 per cent of people presenting at GP practices are undernourished.

This proportion is about three times higher in those recently admitted to care homes (35 per cent), on admission to hospital (29 per cent) and attending hospital outpatients (30 per cent).

Many people seen by community pharmacists seem to be at increased risk of malnutrition including those with chronic obstructive pulmonary disease, cancer, gastrointestinal, renal or liver diseases or inflammatory conditions (e.g. rheumatoid arthritis and inflammatory bowel disease).

People with progressive neurological diseases, such as dementia and Parkinson’s disease, as well as those with frailty and mobility issues, depression or recently discharged from hospital are among several other high-risk groups.

Fundamental

“Nutrition and hydration are the fundamentals for life, and when someone is not meeting their nutritional needs this can significantly impact their health and well-being,” says Filippo Della Torre, general manager of Nutricia Advanced Medical Nutrition UK & Ireland.

“The changing demographics our society faces over the coming decades will lead to an increasing need to manage more older people, with more multi-morbidities and a greater number at risk of suffering nutritional problems.

“The pressures this will bring to our healthcare system mean we will need to be taking an ever more person-centred, community-based approach to care. This places an increasing emphasis on the importance of pharmacists, who are a key point of healthcare contact for patients, carers or general citizens in the community.” 

The guidelines define undernutrition as “a deficiency of energy, protein and other nutrients that causes adverse effects on the body (shape, size and composition), the way it functions and clinical outcomes”.

For example, undernourished people are at increased risk of falls, partly because of their greater frailty and poorer muscle strength. Undernutrition can also undermine recovery from illness and surgery (e.g. poor wound healing), impair immunity and psychosocial function, as well as increasing mortality.

Substantial savings

As a result, the cost of managing undernourished people is three to four times greater than that of managing adequately nourished people, so identifying and treating malnutrition can result in substantial savings.

The guidelines stress the importance of screening, such as using the Malnutrition Universal Screening Tool (included in the report and available at bapen.org.uk). Healthcare professionals using screening tools “should have appropriate skills and training”.

The new guidelines will “drive consistency in the way that the identification, management, and monitoring of malnutrition happens in a timely manner and is most appropriate for an individual,” says Della Torre.

They support opportunistic screening; for example, on GP registration, admission to residential care and by community pharmacists, such as during MURs, when people present with signs that might indicate undernutrition (see table) and are in high-risk groups.

The guidelines also suggest that community pharmacists can be part of a multidisciplinary team that determines the “optimal nutritional strategy”, based on, for example, a patient’s clinical condition and social situation.

Signs and symptoms that might indicate undernutrition

  • Altered bowel habit
  • Altered taste
  • Apathy
  • Appearing thin
  • Difficulty swallowing
  • Fragile skin
  • Loose fitting clothes
  • Muscle wasting
  • Poor appetite
  • Poor wound healing
  • Pressure ulcers
  • Prolonged intercurrent illness
  • Unplanned weight loss


Many people will need specialist (e.g. dietician) support to optimise food intake and, if necessary, use oral nutritional supplements (ONS). According to the guidelines, prescribable nutrition support – which includes ONS, tube feeds and parenteral nutrition – accounts for less than 2.5 per cent of the total expenditure
on malnutrition.

ONS complement and support dietary strategies; they are not food replacements. The guidelines suggest beginning ONS with a starter pack, with pharmacists and other HCPs checking compliance and, if necessary, suggesting different types and flavours to optimise intake. ONS are available in numerous forms (milk, juice, yogurt, savoury), formats (liquid, powder, pudding, pre-thickened), types (high protein, fibre containing, low volume), energy densities (1-2.4kcal/ml) and flavours.

Patients should also be encouraged to “take ONS when they most feel like taking them. This may be between meals, like a snack, first thing in the morning or before bed. ONS can also be incorporated into everyday foods”, such as jellies and sauces, say the guidelines. Pharmacists can help ensure patients receive the regular follow-up and monitoring as outlined in the guidance.

ONS, the guidelines note, seem to improve weight, function (e.g. hand grip strength) and quality of life, while reducing the risk of complications, such as pressure ulcers, poor wound healing and infections. ONS also seem to reduce mortality in acutely ill older people as well as hospital admissions and readmissions.

Tragic irony

There is something of a tragic irony that, as public health focuses on over-nutrition and obesity, millions of people are at risk of potentially preventable problems caused by under-nutrition. More than nine in 10 undernourished people are in the community, making pharmacists a key part of the solution.

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