Management of Malnutrition
The management of malnutrition requires systematic screening, comprehensive assessment, individualized intervention, and regular monitoring with adjustment of interventions based on patient response.
Screening and Assessment
Screening
- All patients should be routinely screened for malnutrition using validated tools 1:
Assessment
- Following positive screening, a comprehensive nutritional assessment must be performed 1:
- Anthropometric measurements (weight, height, BMI)
- Weight history (unintentional weight loss >5% in 3 months or >10% in 6 months)
- Dietary intake evaluation (food records, 24-hour recall)
- Physical examination for signs of malnutrition (muscle wasting, subcutaneous fat loss)
- Laboratory parameters (albumin, prealbumin, electrolytes)
- Functional assessment (hand grip strength, physical performance)
- Assessment of underlying causes of malnutrition
Intervention Strategies
Dietary Modifications
- Provide adequate energy and protein:
- For high-risk patients (BMI <16 kg/m² or no intake >10 days):
- For moderate-risk patients:
- Start with 15-20 kcal/kg/day 2
- Avoid dietary restrictions unless medically necessary 1
- Provide meals in a pleasant, homelike atmosphere 1
Oral Nutritional Support
- Provide dietary advice and oral nutritional supplements (ONS) for patients unable to meet nutritional needs through diet alone 1
- Offer nutritional supplementation to people whose nutritional status is poor or deteriorating 1
- Consider specific nutrient supplementation based on deficiencies:
Enteral and Parenteral Nutrition
- Nasogastric (NG) feeding is the preferred method during the first month for people who do not recover functional swallowing 1
- Reserve parenteral nutrition for patients who cannot tolerate enteral feeding or when the GI tract is non-functional 2
Electrolyte Management
- Proactively supplement electrolytes, even with mild deficiency 2:
- Potassium: 2-4 mmol/kg/day
- Phosphate: 0.3-0.6 mmol/kg/day
- Magnesium: 0.2 mmol/kg/day IV or 0.4 mmol/kg/day orally
- Monitor electrolytes daily during the first 72 hours of refeeding 2
Monitoring and Follow-up
- Monitor food intake for all people with malnutrition 1
- Regularly reassess nutritional status and adjust interventions accordingly 1:
- Watch for early warning signs of refeeding syndrome (night sweats, electrolyte abnormalities) 2
- Continue nutritional support after hospital discharge 2
Special Considerations
Geriatric Patients
- Consider age-related changes in body composition and energy requirements 1
- Provide adequate support for eating difficulties 1
- Education and support for formal and informal caregivers 1
Patients with Obesity
- Screen for malnutrition even in patients with obesity 1, 3
- Recognize that patients with obesity can have protein-energy malnutrition and micronutrient deficiencies 2
- Use adjusted body weight for nutritional calculations in obesity 1
Patients with Chronic Disease
- Identify and address disease-specific nutritional requirements 1
- Implement multidisciplinary approach involving dietitians, nurses, and physicians 4
- Consider pharmacological interventions for specific symptoms:
Pitfalls and Caveats
- Malnutrition is often underdiagnosed, particularly in patients with obesity 5, 3
- BMI alone is not a reliable indicator of nutritional status 5
- Refeeding syndrome can occur within 72 hours of initiating nutritional support in high-risk patients 2
- Fluid overload can mask weight loss and malnutrition 1
- Failure to address underlying causes of malnutrition will limit treatment effectiveness 6
By implementing this systematic approach to malnutrition management, healthcare providers can significantly reduce morbidity, mortality, and healthcare costs associated with malnutrition 6.