General practitioners’ views on malnutrition management and oral nutritional supplementation prescription in the community: A qualitative study

Summary

Background & aims

Malnutrition or undernutrition, arising from a deficiency of energy and protein intake, occurs commonly among community-dwelling individuals in developed countries. Once identified, malnutrition can be effectively treated in the majority of cases with dietary advice and the prescription of oral nutritional supplements (ONS) for patients who can eat and drink orally. However, previous research has reported inadequate screening and treatment of malnutrition in the community. The aim of this qualitative study was to explore general practitioners’ (GPs) experiences and opinions on the management of malnutrition and the prescription of ONS in the primary care/community setting in Ireland.

Methods

Sixteen semi-structured interviews including chart stimulated recalls (CSR) were conducted with GPs. The interviews and CSRs explored, among others, the following domains; barriers and facilitators in the management of malnutrition, ONS prescribing in the primary care/community setting, and future directions in the management of malnutrition and ONS prescribing. Recorded interviews were transcribed and analysed following a generic qualitative approach with inductive thematic analysis using NVIVO 12 to facilitate data management.

Results

Three main themes were identified. Theme 1: ‘Malnutrition is a secondary concern’, encapsulating the idea that the identification of malnutrition is usually secondary to other clinical issues or disease rather than an independent clinical outcome. This theme also includes the idea that obesity is viewed as a dominant nutritional issue for GPs. Theme 2: ‘Responsibility for malnutrition and ONS management in the community’, highlighting that GPs feel they do not know who is responsible for the management of malnutrition in the community setting and expressed their need for more support from other healthcare professionals (HCPs) to effectively monitor and treat malnutrition. Theme 3: ‘Reluctance to prescribe ONS’, emerging from the GPs reported lack of knowledge to prescribe the appropriate ONS, their concern that ONS will replace the patient's meals and the costs associated with the prescription of ONS.

Conclusions

GPs in Ireland do not routinely screen for malnutrition in their clinics as they feel unsupported in treating and managing malnutrition in the community due to limited or no dietetic service availability and time constraints. GPs also view malnutrition as a secondary concern to disease management and prioritise referral to dietetic services for patients with overweight and obesity. GPs reported that they have insufficient knowledge to change or discontinue ONS prescriptions. This study demonstrates that there is a clear need for primary care training in malnutrition identification, treatment and management and more community dietetic services are needed in order to support GPs and deliver high quality care to patients.

Introduction

Malnutrition or undernutrition, arising from a deficiency of energy and protein intake, occurs commonly among community-dwelling individuals in developed countries [1,2]. Malnutrition has a significant impact on affected individuals’ quality of life due to increased susceptibility to disease and mortality regardless of the health condition it is associated with [3,4]. Patients discharged from acute settings who are malnourished are more likely to be re-admitted [5,6]. In the UK, it is estimated that approximately 3 million people are at risk of malnutrition, of which nearly half are aged over 65 years, the majority living in the community [1]. In Ireland, it is estimated that there are 140,000 adults with disease-related malnutrition at any time, with an annual estimated cost of €1.4 billion which represents 10% of annual health care expenditure [7].

Malnutrition is common among older people, being predominantly associated with disease in the majority of cases in this population group. However, it can also occur in the absence of disease due to physiological (e.g. reduced taste and smell) and non-physiological factors (e.g. loneliness) [8]. The ageing of the world's population suggests that the incidence of malnutrition will increase in the community setting. In 2018, for the first time in history, there were globally more people ≥65 years than children under 5 years of age. By 2050 it has been estimated that there will be more than twice as many people ≥65 than children ≤5 years [9]. Moreover, although older people represent a large percentage of the population affected by malnutrition, other groups also living in the community, such as cancer patients or patients with chronic conditions, are also at risk of becoming malnourished [10,11].

Both in the UK and Ireland, it is estimated that 10% of the population requiring care from a GP are at risk of malnutrition [12]. Despite the large population at risk of malnutrition and its associated health implications, it is a condition that is often undiagnosed and untreated [13,14]. Many reasons have been suggested for the under-diagnosis of malnutrition; these include the absence of nutrition education in medical school curricula and postgraduate training, and the unclear “ownership” of malnutrition care among health care professionals (HCPs) [15,16]. In fact, until very recently, there has been a lack of consensus on the diagnostic criteria to identify malnutrition in the clinical setting [17]. In an attempt to harmonise malnutrition diagnostic criteria, the Global Leadership Initiative on Malnutrition (GLIM) has recently developed new principles for the diagnosis of malnutrition, combining phenotypic factors (weight loss; reduced muscle mass and reduced body mass index [BMI]) and aetiological factors (reduced food intake; impaired assimilation disease burden and inflammation) [18].

Malnutrition in the community is optimally treated by providing first-line dietary advice a so-called “food-first” approach in combination with ONS when necessary (Fig. 1) [19]. A recent systematic review of randomized controlled trials in the hospital and community setting looking at nutritional interventions in older adults at risk of malnutrition indicated that ONS combined with dietary counselling is the most effective intervention, increasing both dietary intake and weight [20]. ONS are an effective method of managing malnutrition if prescribed for patients who are malnourished or at risk of malnutrition [21]. Criteria for the appropriate prescribing of ONS have been proposed; appropriate prescribing encompasses several factors; nutritional screening and assessment of the individual to ascertain the need for ONS (malnutrition or at risk of malnutrition), investigation of the underlying causes of malnutrition, establishing desirable outcomes to be obtained from the nutritional support (i.e. weight increase), and providing both dietary advice and continuous ONS monitoring to assess their need and patient adherence (Fig. 1) [22,23]. However, previous research indicates that inappropriate prescribing of ONS occurs frequently in the community setting (30–70% prevalence) which has both economic and, potentially, clinical implications [[24], [25], [26]].

Inappropriate ONS prescribing includes the following possibilities; over-prescribing or prescribing in the absence of a diagnosis of malnutrition or risk of malnutrition; mis-prescribing or prescribing wrong doses and/or treatment duration; and under-prescribing or the lack of ONS prescribing when there is malnutrition or risk of malnutrition [27]. Previous Irish research has demonstrated that management of patients ‘at risk’ of malnutrition in the primary care/community setting is sub-optimal, with low awareness of the condition and its management among non-dietetic HCPs [25,28]. In Ireland, GPs are the main prescribers of ONS in primary care. They are also commonly the first point of contact for individuals in the community who are malnourished or at risk of malnutrition [25,28]. Therefore, exploring their experiences and perceptions can provide insight into the complexities of managing malnutrition and ONS prescribing in the community. The aim of this qualitative study was to explore GPs' experiences and opinions on the management of malnutrition and the prescription of ONS in the primary care/community setting in Ireland.