Abstract
Background & aims: Malnutrition or undernutrition, arising from a deficiency of energy and protein intake, occurs commonly among community-dwelling individuals in developed countries. Once identified, malnutrition can be effectively treated in the majority of cases with dietary advice and the prescription of oral nutritional supplements (ONS) for patients who can eat and drink orally. However, previous research has reported inadequate screening and treatment of malnutrition in the community. The aim of this qualitative study was to explore general practitioners’ (GPs) experiences and opinions on the management of malnutrition and the prescription of ONS in the primary care/community setting in Ireland. Methods: Sixteen semi-structured interviews including chart stimulated recalls (CSR) were conducted with GPs. The interviews and CSRs explored, among others, the following domains; barriers and facilitators in the management of malnutrition, ONS prescribing in the primary care/community setting, and future directions in the management of malnutrition and ONS prescribing. Recorded interviews were transcribed and analysed following a generic qualitative approach with inductive thematic analysis using NVIVO 12 to facilitate data management. Results: Three main themes were identified. Theme 1: ‘Malnutrition is a secondary concern’, encapsulating the idea that the identification of malnutrition is usually secondary to other clinical issues or disease rather than an independent clinical outcome. This theme also includes the idea that obesity is viewed as a dominant nutritional issue for GPs. Theme 2: ‘Responsibility for malnutrition and ONS management in the community’, highlighting that GPs feel they do not know who is responsible for the management of malnutrition in the community setting and expressed their need for more support from other healthcare professionals (HCPs) to effectively monitor and treat malnutrition. Theme 3: ‘Reluctance to prescribe ONS’, emerging from the GPs reported lack of knowledge to prescribe the appropriate ONS, their concern that ONS will replace the patient’s meals and the costs associated with the prescription of ONS. Conclusions: GPs in Ireland do not routinely screen for malnutrition in their clinics as they feel unsupported in treating and managing malnutrition in the community due to limited or no dietetic service availability and time constraints. GPs also view malnutrition as a secondary concern to disease management and prioritise referral to dietetic services for patients with overweight and obesity. GPs reported that they have insufficient knowledge to change or discontinue ONS prescriptions. This study demonstrates that there is a clear need for primary care training in malnutrition identification, treatment and management and more community dietetic services are needed in order to support GPs and deliver high quality care to patients.
Abstract from Dominguez Castro P, Reynolds CM, Kennelly S, et al.: General practitioners’ views on malnutrition management and oral nutritional supplementation prescription in the community: A qualitative study. Clin Nutr ESPEN 2020;36:116–127.
Knowledge Transfer of Dietitian Trude M. Backer Mortensen (Oppegård)
Background
Malnutrition occurs alongside obesity in the Western world. The incidence varies in different age groups and depends on disease status [5]. For elderly people living at home, the rate of malnourishment is 10–14% [8, 13]. Early detection and intervention increase the chance of avoiding manifest malnutrition and may also positively affect quality of life, health and physical functioning, and decrease the risk of falls and disease development [6, 13].
Home-dwelling, self-reliant elderly people mainly visit their general practitioner (GP) while other specialists are only seen in the event of acute illness or increasing frailty necessitating a higher level of assistance with daily living.
Lack of Nutritional Risk Screening in GP Practices
It is common procedure for patients in hospital, nursing home, and home care settings to be regularly surveyed for nutritional risk, with established guidelines available for nutritional status screening. For home-dwelling, self-reliant elderly people, regular screening of nutritional status by a GP is less common, and guidelines are less clear for these patients [1]. Screening for risk of malnutrition is often carried out with validated mapping tools. Some tools are best suited for use in hospital settings while others are more suitable for use in home residents [7, 12].
Conclusion for Clinical Practice
If GPs regularly mapped the nutritional status of elderly patients, nutritional measures could be implemented at an earlier stage and fewer elderly people would be malnourished. This could decrease the financial burden at both the societal and the individual level [4, 9]. For patients, it could decrease ill health, illness, and reduced quality of life [7] as malnutrition increases the risk of illness and falls, delays wound healing and rehabilitation, and can affect mental functioning [11].
In order to map the nutritional status of elderly people living at home, GPs must understand the importance of prevention and treatment of malnutrition, know how to implement nutritional measures best, and perceive it as their responsibility to do so [13].
Guidelines must be established to determine who is to be screened for nutritional risk, how and how often this should be done, and which tools are to be used, in correspondence with existing guidelines pertaining to hospitals, nursing homes, and home care. These guidelines should be based on documented evidence regarding the prevalence of the risk of malnutrition in different population groups and on the tools shown to be most suitable in the primary health care setting [2, 10].
Furthermore, there need to be regular follow-up examinations in relation to risks detected [3, 12]. In busy general practice with little time for the individual patient, this can be demanding to achieve. Nevertheless, there can be no doubt as to the importance of early implementation of measures to prevent malnutrition. Establishing primary care “health teams” consisting of different healthcare professionals could make it easier to regularly map the nutritional status of the most vulnerable patient groups and implement and evaluate measures early on [2]. The actual screening of a patient’s nutritional status could also be done by a healthcare professional other than the GP, e.g. a nurse. A dietitian could follow up on findings of nutritional risk and malnutrition and possibly recommend a prescription for oral nutritional supplements. Evaluation of implemented measures should be done within an interdisciplinary group setting including the patient, the GP, and those carrying out the nutritional screening and implementing nutritional measures.
Disclosure Statement
I hereby declare that there are no conflicts of interest with regard to this commentary.
