Malnutrition, often termed ‘poor nutrition,’ arises from deficiencies in energy and essential nutrients, leading to clinically significant adverse effects on body composition and function.1 While malnutrition can technically include overnutrition, it predominantly refers to undernutrition, a condition affecting an estimated 3 million individuals in the UK, with a significant majority (93%) living within the community.2 Malnutrition is both a cause and consequence of illness, representing a widespread yet frequently overlooked health concern in primary care settings.3,4 This oversight may stem from a historical emphasis on addressing overeating and obesity in weight management and nutritional health strategies.
The detrimental effects of malnutrition are far-reaching, impacting disease risk, progression, and prognosis, while also increasing post-injury complications and impeding recovery from illness. This translates to heightened healthcare demands in the community, including increased reliance on GP services and home care. Recent data indicates that the annual cost of malnutrition to health and social care in England alone exceeds £19 billion, with half of this expenditure attributed to individuals over 65 years.3 Notably, treating a malnourished patient costs over three times more than treating a well-nourished patient. This economic burden is projected to escalate with an aging population and the rising expenses of health and social care.
The Critical Role of Screening and Treatment
Older adults are particularly vulnerable to malnutrition, a risk often underestimated due to the misconception that weight loss is an inevitable aspect of aging. Malnutrition intensifies age-related muscle mass and strength decline, contributing to sarcopenia and increased frailty.5 Early detection and intervention through effective screening and a tailored care plan are crucial in mitigating the clinical risks linked to malnutrition, such as increased susceptibility to illness, clinical complications, and mortality. Given that most cases of malnutrition originate in community settings, primary care is the optimal point for early identification.
The National Institute for Health and Care Excellence (NICE) guidelines advocate for routine screening of patients by GPs upon registration and whenever clinical concerns arise.6,7 Opportunistic screening is also recommended during routine health assessments and seasonal vaccinations. Care home residents should also undergo regular screening. NICE guidelines specifically recommend weighing patients, calculating Body Mass Index (BMI), and utilizing a validated screening tool such as the Malnutrition Universal Screening Tool (MUST).2
Developed by the multidisciplinary Malnutrition Advisory Group of the British Association for Parenteral and Enteral Nutrition (BAPEN), MUST employs three independent criteria for risk assessment:2,8
- BMI to assess current weight status;
- Documentation of unintentional weight loss, as evidence suggests that a 5–10% weight loss can significantly impair physiological functions;2
- Acute disease impact, identifying conditions likely to result in nil nutritional intake for more than 5 days.
Each criterion is scored on a scale of 0–2. The cumulative score categorizes patients into low (0), medium (1), or high (≥2) risk groups for malnutrition. Patients identified at medium or high risk require a structured nutrition management care plan, guided by a malnutrition pathway.9 This pathway delineates the need for specialist dietary advice, meal assistance, food-first strategies, or prescriptions for oral nutritional supplements (ONS). While local guidelines may vary, GPs can access relevant protocols from community dietitians, such as the referral pathway implemented in Dorset.10 Care plans for medium- and high-risk patients should include clear, measurable goals and scheduled review dates for nutritional status.
Primary Care Implementation Gaps
Despite clear recommendations, malnutrition screening and management in primary care appear to be underprioritized. Routine screening using validated tools, like MUST, is not consistently integrated into care planning, particularly for individuals over 75. Contributing factors may include insufficient knowledge and training among primary care providers, an undue focus on obesity and overeating as primary public health concerns, a lack of clear leadership or ownership among GPs who might delegate this responsibility to practice nurses or dietitians, resource limitations, funding constraints, and an already demanding clinical workload.3
A retrospective review conducted within a small GP surgery in Dorset, serving a significant older population (14.2% of registered patients over 75), highlighted these gaps. While 76% of older patients had a BMI recorded in the past two years, only 3% were underweight (BMI <18.5 kg/m2). Alarmingly, of these underweight patients, only 8% had a documented MUST score, and only 33% had evidence of receiving dietary advice. Dietitian referrals and ONS prescriptions were similarly low, at 25% and 33% respectively. This patient group demonstrated high rates of primary care consultations, averaging 12 nurse contacts per year, largely due to pressure sores and ulcers. These findings align with broader evidence indicating inadequate malnutrition screening using validated tools like MUST and suboptimal clinical management.
Conclusion: Integrating MUST and Care Plans for Improved Patient Outcomes
Systematic screening and effective management of malnutrition are critical clinical imperatives that have been insufficiently addressed in primary care. Relying solely on BMI measurement is inadequate. Adoption of validated malnutrition screening tools, such as MUST, is essential to enhance nutritional care, identify at-risk individuals, and guide appropriate interventions, including supplementation and professional dietary counseling. Raising awareness about community malnutrition, its impact on patient outcomes, and its considerable economic burden on healthcare systems is paramount. To facilitate this, GPs require accessible training, primary care teams need to establish clear roles for managing patient nutritional needs (whether led by GPs, nurses, or dietitians), and healthcare commissioners must consider implementing incentives,11 developing local protocols, and allocating necessary resources. Integrating community dietitians more comprehensively within primary healthcare teams, particularly within evolving care models, presents a valuable opportunity to improve malnutrition management.
Initiatives such as the Malnutrition Task Force (http://www.malnutritiontaskforce.org.uk/) and BAPEN (http://www.bapen.org.uk/) are actively working to address malnutrition. The Wessex Academic Health Science Network’s Nutrition in Older People Programme has further contributed by evaluating integrated approaches and resources, including the Older People’s Essential Nutrition (OPEN) toolkit, with freely available materials.12
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
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