Despite the association of poor nutritional status with increased morbidity and mortality in a wide range of medical conditions, malnutrition is not well understood. Malnutrition is not based exclusively on the patient’s body mass index (BMI). In fact, there is a high prevalence of malnutrition in older adults with excess weight and obesity.  Malnutrition is defined as a state resulting from lack of intake or uptake of nutrition that leads to altered body composition (decreased fat free mass) and body cell mass leading to diminished physical and mental function as well as impaired clinical outcomes from disease.

It is estimated that 8.9 percent of the world’s population—663 million people—are undernourished. Don’t make the mistake of thinking that malnutrition is solely a problem of the developing world. Malnutrition affects 33 million people in Europe alone, and it is not uncommon in Canada and the United States either.  In 2020, undernourishment in Canada was reported at 2.5 percent of the population, and in 2021, 10.2 percent of US households were food insecure at some point during the year. While not as severe as malnutrition, undernourishment is defined as habitual food consumption that is insufficient to provide the dietary energy levels required to maintain a normal level of activity and a healthy life.

Approximately one-third of Canadian community-dwelling older adults are at nutritional risk, and up to 10 percent of community-dwelling older adults have been identified as malnourished. These statistics could even be an underestimate due to the infrequency of nutritional assessments in this patient population.

In a multicentre study published in 2016, the prevalence of malnutrition on admission to Canadian hospitals was 45 percent in medical and surgical patients who stayed in hospital for longer than two days. Patients who are malnourished have hospital stays that are 34 to 53 percent longer and cost the healthcare system 31 to 55 percent more than patients who are well nourished.

Primary care clinicians can help to identify patients early in the course of malnutrition and make adjustments to reduce the impact it has on their health and wellbeing. A recent review of 26 randomized clinical trials concluded that primary care referrals of patients who are at risk for malnutrition for nutritional assessment and intervention are effective in improving patients’ dietary intake and quality.

Are You Prepared?

How prepared are you to identify the risk for malnutrition in your patients? Can you answer these three questions correctly?

1) Which of the following is a risk factor for malnutrition?

• Being 50 years of age and older
• Cognitive decline
• Caucasian descent
• Living and eating with a family or caregiver

2) How frequently should older adults (> 65 years) be screened for malnutrition?

• Every 6 months
• Annually
• Every 3 to 5 years
• Only if they show symptoms of malnutrition

3) If a patient at risk for malnutrition is being assessed by a primary care clinician, when should the clinician consider a referral to a registered dietitian for a malnutrition assessment?

• All patients > 65 years of age
• Patients who have a BMI < 25 kg/m2
• Patients at high malnutrition risk
• Referrals to a registered dietitian are normally used for inpatient consultations and are not generally required for primary care clinicians

Be Prepared to Help Your Patients

Once a patient has been identified as potentially at risk for malnutrition, the next step is to determine if the patient is at low risk, moderate risk, high risk, or is already malnourished. This determination will guide the next steps in the patient’s management.

It is important for primary care practitioners to know the treatment pathway for each level of nutritional risk. If you are unsure of how to address your patients’ needs, you can explore a complimentary MDBriefCase course, Screen and Intervene Now – Reducing the Impact of Malnutrition in your Patients. If you aren’t already a member, join the MDBriefCase community today for free.