Disease-related malnutrition is a growing and costly healthcare challenge that is found across all health and social care settings. Malnutrition is associated with increased admissions to hospital, longer durations of hospital stay, increased complication rates and earlier hospital readmissions. The overall result is significantly increased healthcare costs associated with managing individuals with malnutrition. Thankfully, the majority of malnutrition is treatable if it is identified and there is evidence to suggest nutritional support is one of the most clinically and cost-effective treatments available to healthcare systems around the world. Dietitians are uniquely trained to provide individualised nutritional advice based on the latest clinical evidence and have a variety of strategies available to them, including food-based, oral nutritional supplements (ONS) and a combination of strategies. However, there remains confusion around the optimum method of oral nutritional support for the first-line management of malnutrition in patients, as a result practice varies.
A recent publication accepted in the Journal of Human Nutrition and Dietetics surveyed the 7,551 British Dietetic Association (BDA) members at the time (6,486 UK-based) to explore the opinions and practice around oral nutritional support in the management of malnutrition. Two-hundred and seven (n 207) dietitians provided full responses outlining their level of agreement or disagreement with various statements. When asked what different factors influenced their choice in selecting oral nutrition support interventions, 93% reported that ease of implementation was a strong factor, 89% based on a department protocol and 80% on published research. The survey provides a fascinating insight in to the variability of clinical dietetic practice with regards to first-line malnutrition management strategies and whether dietitians felt practice was evidence-based. Surveyed dietitians were asked to indicate their agreement with several statements to the following question ‘when selecting oral nutrition support interventions for patients who are malnourished or at risk of malnutrition…’:
- a food first approach should be adopted: 80.7% agreed or strongly agreed
- oral nutritional supplements should be used as a first-line strategy: 4.7% agreed or strongly agreed
- food-based and ONS strategies should be combined as a first-line approach: 26.6% agreed or strongly agreed
- current dietetic practice is evidence-based: 48.3% agreed or strongly agreed
- current dietetic practice is largely based on the clinical judgement of the dietitian: 77.3% agreed or strongly agreed
- ONS are clinically superior to dietary counselling/food-based interventions: 4.4% agreed or strongly agreed
The researchers highlight there is an underlying assumption in many current policies that food-based interventions can achieve the same outcomes as ONS despite the evidence base being stronger for ONS. In addition, only a quarter of dietitians were in agreement that ONS should be combined with food-based strategies. This may be why many policies suggest food-based interventions should be first-line with ONS used as an escalation strategy. However, this does raise issues around the provision of safe care that is also evidence-based, clinically and cost-effective and could underly why over 50% of dietitians failed to agree that current dietetic practice was evidence based. What is certain is the management of malnutrition is incredibly complex and will be influenced by lots of factors including the underlying cause of the malnutrition, whether the person is at risk of malnutrition or is already malnourished, the ability to safely provide ongoing monitoring of nutritional intake, nutritional status, escalation of care as needed, plus many more factors that dietitians consider at the individual level.
The findings of this research support many of the reasons why we started Nutrition Cloud which is to help reduce the variability in the nutritional care that patients receive and assist dietitians through embedded evidence-based clinical nutrition pathways (local, national and/or international). As highlighted in this research, protocols and ease of implementation are critical for busy dietitians both in the hospital and in the community. Nutrition Cloud also enables dietitians to remotely monitor patients’ progress and adherence to treatment so if escalation of nutritional care is needed it can be easily facilitated remotely through the platform and importantly for patients, not necessarily require another home visit or visit to the clinic. Lastly, the researchers highlight the need for clinical guidance based on studies comparing various forms of nutrition support in the first-line management of malnutrition. Our research group in Brisbane has carried out come interesting work investigating the effectiveness of single and combination oral nutritional strategies in malnourished patients which we home to publish over the coming months. We also have some exciting projects planned investigating whether Nutrition Cloud can enhance the delivery of nutritional strategies leading to improved patient outcomes.
If you have any research projects planned and would be interested in using Nutrition Cloud, please get in touch: [email protected]
Reference: Gibbs M et al., Oral nutritional support interventions for patients who are malnourished or at risk of malnutrition: a survey of clinical practice amongst UK dietitians. J Hum Nutr Diet. (2018).