How to manage malnutrition?

Managing Malnutrition: A Systematic Approach

All patients should be systematically screened for malnutrition using a validated tool (MST, MUST, or NRS-2002), followed by comprehensive assessment and individualized multimodal intervention when risk is identified. 1

Step 1: Universal Screening

Screen every patient regardless of body weight, BMI, or diagnosis - this includes overweight and obese individuals who can still be malnourished. 1

Screening Tools by Setting:

• Hospital patients: Use NRS-2002 1
• Community-dwelling older adults: Use MUST or MST 1
• Geriatric patients: Use Mini Nutritional Assessment-Short Form (MNA-SF) 1
• Cancer patients: Screen early in the course of care, regardless of weight history 1

Screening Frequency:

• Hospital admission: Screen immediately upon admission 1
• Long-term care residents: Every 3-6 months if stable 1
• Community patients with chronic disease: Every 3-6 months 1
• Acute health changes: Screen immediately when condition changes 1

Step 2: Comprehensive Assessment (When Screening Positive)

A positive screen mandates detailed nutritional assessment within days, not weeks. 1

Assessment Components:

Dietary Intake Monitoring: Document actual food/fluid consumption for several days using plate diagrams to quantify intake versus requirements 1

Anthropometric Measurements: 1, 2

• Current weight and BMI
• Recent weight loss (percentage and timeframe)
• Mid-upper arm circumference
• Presence of edema or ascites

Body Composition Analysis: Assess muscle mass and fat stores, as weight alone is insufficient 1, 3

Functional Assessment: 1

• Physical function and strength
• Activities of daily living
• Eating ability and independence

Laboratory Evaluation: 4

• Initial panel: Vitamin B12, folate, vitamin D, iron studies (ferritin, transferrin saturation)
• Inflammatory markers: C-reactive protein (to interpret albumin correctly)
• Serum albumin: Every 3 months in at-risk patients (recognizing this reflects inflammation/disease severity, not just nutrition)
• Additional micronutrients if indicated: zinc, copper, selenium, thiamine (especially with rapid weight loss, vomiting, alcohol use)

Identify Underlying Causes: 1

• Dysphagia (requires speech-language pathology evaluation)
• Inadequate food access or preparation ability
• Anorexia or early satiety
• Malabsorption
• Hypermetabolic states
• Medication side effects
• Depression or cognitive impairment

Step 3: Individualized Intervention

Refer to a registered dietitian nutritionist for development of a personalized nutrition care plan - this is non-negotiable for optimal outcomes. 1, 3

Intervention Hierarchy:

First-Line: Dietary Counseling and Food-Based Approaches 1

• Individualized meal plans emphasizing nutrient-dense, minimally processed foods
• Increase meal frequency (5-6 small meals daily)
• Fortify foods with protein powder, oils, or other calorie-dense additions
• Address specific eating problems (texture modifications, adaptive equipment, feeding assistance)
• Provide practical education to patients and caregivers

Second-Line: Oral Nutritional Supplements (ONS) 1

• Indicated when: Dietary counseling alone cannot meet nutritional needs
• NOT indicated: Routine use in well-nourished patients without dysphagia 1
• Evidence: Improves energy/protein intake, body weight, and functional status in malnourished patients 1
• Typical prescription: 400-600 kcal/day from high-protein supplements

Third-Line: Enteral Nutrition 1

• Consider when oral intake remains inadequate despite counseling and ONS
• Requires assessment of swallowing safety and gastrointestinal function

Fourth-Line: Parenteral Nutrition 1

• Reserved for patients with non-functional or inaccessible gastrointestinal tract

Multimodal Approach for Complex Cases:

For cancer-related malnutrition: 1

• Combine nutritional support with anti-inflammatory strategies
• Address anorexia pharmacologically if present
• Incorporate physical activity/resistance training
• Monitor resting energy expenditure

For neurological conditions (stroke, MS, dementia): 1

• Multidisciplinary team including dietitian, speech-language pathologist, occupational therapist, physiotherapist
• Address dysphagia with texture modifications and safe swallowing strategies
• Evaluate eating posture and need for adaptive equipment
• Provide caregiver education and support

Step 4: Monitoring and Adjustment

Reassess within several days to verify goal achievement; adjust plan if targets not met. 1

Monitoring Parameters:

• Weight: Weekly during acute intervention, then monthly 1
• Dietary intake: Daily documentation until stable 1
• Functional status: Monthly using validated tools 1
• Laboratory markers: Every 3 months until stabilized, then at least annually 4

Goals:

• Prevent further weight loss initially 1
• Achieve minimum 5% weight gain in underweight patients 3
• Maintain or improve muscle mass and function 1
• Improve quality of life 1, 3

Critical Pitfalls to Avoid

Do not wait for severe malnutrition before intervening - early detection and treatment prevent complications and reduce mortality. 1, 5

Do not rely on albumin alone - it reflects inflammation and disease severity more than nutritional status; always assess inflammatory markers concurrently. 4

Do not assume normal or high BMI excludes malnutrition - sarcopenic obesity is real; screen all patients. 1

Do not provide routine ONS to well-nourished patients - this wastes resources without benefit. 1

Do not neglect the transition of care - nutritional information is frequently lost at discharge; ensure continuity with outpatient providers. 1

Do not underestimate caregiver burden - provide adequate education and support to family members and professional caregivers. 1

Institutional Requirements

Establish standard operating procedures with clear responsibilities for screening, assessment, and intervention. 1

Constitute a multidisciplinary nutrition team including dietitian, nurse, physician, and other relevant professionals who meet regularly. 1

Ensure dietitian participation in team conferences to integrate nutritional interventions into overall care plans. 1

Provide adequate resources and education to all staff regarding nutrition screening and basic interventions. 1