Addressing the malnutrition gap requires high-quality research, recognition of intervention complexity, and equitable implementation strategies

Malnutrition, encompassing both undernutrition and overnutrition, is a growing concern among older adults globally, affecting 25% of this population and up to 50% in hospital or nursing home settings (1,2). It leads to severe health issues such as sarcopenia, frailty, immune dysfunction, reduced quality of life and increased mortality. Effective management requires routine screening, comprehensive nutritional assessment, and individualized interventions such as nutritional counselling and food systems review, including food fortification and oral nutritional supplements. However, gaps between evidence-based guidelines and clinical practice often arise due to resource limitations and inadequate prioritization of nutritional care (1,2). Additionally, given the proliferation of clinical practice guidelines on malnutrition for diverse populations and conditions, clinicians must discern which guidelines are most trustworthy (3,4) by asking six key questions:

• Are the recommendations clear and unambiguous?
• Have the panellists considered all possible therapeutic, diagnostic, or prognostic alternatives?
• Have all clinically important outcomes been considered?
• Is the recommendation based on the latest systematic review?
• Does the strength of the recommendation match the certainty of the evidence?
• Were potential conflicts of interest identified and managed?

By addressing these questions, clinicians can better determine the reliability and integrity of clinical practice guidelines. The Evidence-based Nutrition Practice Guideline recently released by the Academy of Nutrition and Dietetics, which focused on the nutrition care of older adults in long-term care (LTC) and community settings (5), meets these criteria. Developed by a panel of experts following a well-designed methodology, including original systematic reviews and meta-analyses, validated through peer review and public consultation, this guideline provides robust, evidence-based nutritional recommendations for registered dietitian nutritionists. Practical tools and resources were also developed to facilitate implementation, and a framework for ongoing evaluation ensures the guidelines remain current (5). The key recommendations of this guideline are summarised and presented here:

• Nutrition Assessment Tools:
  • Mini Nutritional Assessment (MNA): recommended for malnutrition assessment in both LTC and community settings. [Low certainty of evidence]
  • Subjective Global Assessment (SGA) and Patient-Generated SGA (PG-SGA): consider if MNA is not feasible in LTC and community settings. [Consensus statement]
• Oral Nutrition Supplements (ONS):
  • Community, post-discharge and LTC: recommended 1–2 times daily for those with or at risk of malnutrition, primarily to increase energy and protein intake only. [Low to moderate certainty of evidence]
• Effective dietitian interventions:
  • Community and post-discharge: recommended for weight maintenance, desired weight gain, and increased energy and protein intake. [Low certainty of evidence]
• Food fortification:
  • Part of a comprehensive nutrition intervention in both LTC and community settings, primarily to increase energy and protein intake only. [Consensus statement]
• Meals-on-wheels and congregate meals:
  • Recommended for older adults at risk of malnutrition in the community. [Low certainty of evidence]

Implementing these evidence-based guidelines can significantly improve the quality of nutrition care for older adults in community and LTC settings. While there are similar guidelines aiming to address malnutrition in the community (6) or post-discharge (7), they fall short in terms of methodological rigour (7), stakeholder involvement (7), evidence generating and grading (6,7), conflict of interests management (7), and practical implementation considerations (7) when compared to the guidelines by Riddle et al. [2024] (5).

More research is needed on the validity, reliability, and feasibility of nutrition assessment tools and the effectiveness of dietitian interventions (5). Dietitians play an indispensable role in preventing and treating malnutrition among older adults, particularly those in LTC and community settings (8). By implementing evidence-based nutrition, registered/credentialed dietitians are the key to better health outcomes and more efficient use of healthcare resources (9). In addition to providing direct nutrition care and individualized medical nutrition therapy (MNT), they play a vital role in educating individuals, caregivers, and LTC staff to enhance the quality of nutritional care for older adults. Beyond these roles, dietitians develop strategies, identify and navigate barriers such as referral pathways, insurance coverage, and service availability, and address broader food system challenges (9).

However, in the United States, where this guideline was developed, implementing nutritional support, particularly for vulnerable populations and those of lower socioeconomic status, encounters several challenges, partly due to payment methods and insurance coverage limitations (10). The lack of evidence supporting the cost-effectiveness of nutritional interventions may deter additional funding support from implementing the guidelines (11). This discrepancy can partly be explained by the limited evidence from nutritional interventions in cost-effectiveness analyses, where quality-adjusted life years (QALYs) are more commonly used in research trials that provide evidence supporting clinical guidelines. Disability-adjusted life years (DALYs) can be a more effective measure of malnutrition’s long-term impact, particularly in vulnerable and older populations. In large healthcare systems, dietitians’ effective management of malnutrition has been demonstrated to significantly reduce DALYs (9).

The other challenge and limitation of this and various other clinical guidelines for malnutrition lies in the difficulty in demonstrating high certainty of evidence for outcomes of nutritional interventions (12,13). Factors contributing to this include:

• Complexity of disease and intervention: malnutrition is a complex disease often co-existing with other acute or chronic illnesses. Furthermore, nutritional interventions are inherently complex, containing several interacting components, and show characteristics of emergence, feedback, adaptation, and self-organization, complicating the assessment of their isolated impact (14).
• Adherence and dropout rates: nutritional interventions often require long-term commitment, leading to issues with participant adherence and high dropout rates. These factors can skew results and make it challenging to draw definitive conclusions about the effects of specific nutrients (12).
• Long follow-up periods: to observe the effects of intervention on outcomes like mortality or quality of life, research studies need to follow participants for extended periods, sometimes decades. This requirement adds to the complexity and cost of conducting such studies (12).
• Study design limitations: randomized controlled trials (RCTs), considered the gold standard for clinical research, have limitations in nutrition studies. These include the difficulty of maintaining strict dietary controls and the ethical concerns of long-term nutritional interventions. While prospective observational studies can overcome some limitations of RCTs, they are inherently prone to biases and confounding factors, which can affect the reliability of their findings (15).

In conclusion, this guideline underscores the importance of providing a comprehensive, individualized nutrition care plan for older adults to prevent and address malnutrition. The systematic approach to assessment and intervention is rigorous and strongly emphasizes dietitians’ role and the necessity for continuous research to address the existing knowledge gaps. When implemented, it is expected to enhance the identification of malnutrition, standardize care protocols, ensure individualized nutrition care, foster interprofessional collaboration, and improve outcomes for older adults with or at risk of malnutrition. The challenges identified also highlight the complexities inherent in malnutrition and the interventions involved, which underscore the need for meticulous interpretation of study results to inform nutritional guidelines and clinical practice.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, HepatoBiliary Surgery and Nutrition. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-482/coif). J.D.B. has previously received speaker fees from Nutricia. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Dent E, Wright ORL, Woo J, et al. Malnutrition in older adults. Lancet 2023;401:951-66. [Crossref] [PubMed]
2. Cederholm T, Bosaeus I. Malnutrition in Adults. N Engl J Med 2024;391:155-65. [Crossref] [PubMed]
3. Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ 2010;182:E839-42. [Crossref] [PubMed]
4. Bero L. Developing reliable dietary guidelines. BMJ 2017;359:j4845. [Crossref] [PubMed]
5. Riddle E, Munoz N, Clark K, et al. Prevention and Treatment of Malnutrition in Older Adults Living in Long-Term Care or the Community: An Evidence-Based Nutrition Practice Guideline. J Acad Nutr Diet 2024;124:896-916.e24. [Crossref] [PubMed]
6. Holdoway A, Anderson L, Ashworth A, et al. Managing adult malnutrition in the community: A guide to managing disease-related malnutrition, including a pathway for the appropriate use of oral nutritional supplements (ONS). Produced by a multi-professional consensus panel.2021 01 Aug 2024. Available online: https://www.malnutritionpathway.co.uk/library/managing_malnutrition.pdf
7. Ng DHL, Koh FHX, Yeong HEL, et al. Nutrition Care after Hospital Discharge in Singapore: Evidence-Based Best-Practice Recommendations. Nutrients 2023;15:4492. [Crossref] [PubMed]
8. Wong A, Huang Y, Sowa PM, et al. Effectiveness of dietary counseling with or without nutrition supplementation in hospitalized patients who are malnourished or at risk of malnutrition: A systematic review and meta-analysis. JPEN J Parenter Enteral Nutr 2022;46:1502-21. [Crossref] [PubMed]
9. Wong A, Huang Y, Banks MD, et al. A Cost-Consequence Analysis of Nutritional Interventions Used in Hospital Settings for Older Adults with or at Risk of Malnutrition. Healthcare (Basel) 2024;12:1041. [Crossref] [PubMed]
10. Perugini M, Johnson TJ, Beume TM, et al. Are We Ready for a New Approach to Comparing Coverage and Reimbursement Policies for Medical Nutrition in Key Markets: An ISPOR Special Interest Group Report. Value Health 2022;25:677-84. [Crossref] [PubMed]
11. Thomson K, Rice S, Arisa O, et al. Oral nutritional interventions in frail older people who are malnourished or at risk of malnutrition: a systematic review. Health Technol Assess 2022;26:1-112. [Crossref] [PubMed]
12. Wong A, Huang Y, Sowa PM, et al. An Umbrella Review and Meta-analysis of Interventions, Excluding Enteral and Parenteral Nutrition, Initiated in the Hospital for Adults with or at Risk of Malnutrition. Am J Clin Nutr 2023;118:672-96. [Crossref] [PubMed]
13. Baldwin C. Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults. Cochrane Database Syst Rev 2021;12:CD002008. [PubMed]
14. Wong A, Huang Y, Banks MD, et al. A Conceptual Study on Characterizing the Complexity of Nutritional Interventions for Malnourished Older Adults in Hospital Settings: An Umbrella Review Approach. Healthcare (Basel) 2024;12:765. [Crossref] [PubMed]
15. Fernainy P, Cohen AA, Murray E, et al. Rethinking the pros and cons of randomized controlled trials and observational studies in the era of big data and advanced methods: a panel discussion. BMC Proc 2024;18:1. [Crossref] [PubMed]