4. Medical nutrition in key guidelines

4. RECOMMENDATIONS FROM KEY GUIDELINES: MEDICAL NUTRITION

Summary

Medical nutrition is increasingly recognised as an integral part of the overall patient management strategy for malnutrition, in hospitals and in the community, based on the evidence that medical nutrition leads to improvements in nutritional intake, body composition, clinical, functional, and economic outcomes.

In many countries, evidence-based guidelines on the management of malnutrition have been developed by national authorities, government agencies, health departments, and professional organisations, and in many cases through collaboration and joint working by these stakeholders. The guidance available covers different patient groups in different care settings, but they consistently include Medical Nutrition as an integral part of patient care. Some include practical advice for healthcare practitioners on how and when to use different forms of nutritional intervention (including ONS and ETF), but there is a need for this practical advice to be strengthened and included more routinely and unambiguously in all guidance documents, ensuring that healthcare providers can apply recommendations in daily practice. In addition, regular reassessment of the patient’s nutritional needs and the appropriateness of ongoing medical nutrition interventions is now increasingly emphasised in updated guidelines.

Patients with complex and often chronic conditions are highly susceptible to the negative consequences of malnutrition. Professional groups with expertise in nutrition including ESPEN, ASPEN and the Academy of Nutrition and Dietetics have led the field in developing extensive guidance on the management of malnutrition in a variety of patient groups including older people, people with cancer, dementia, gastrointestinal disease, COPD and spinal injury. These evidence-based guidelines describe the circumstances in which medical nutrition should be used as part of a range of strategies to provide optimal nutritional care. Emerging evidence also highlights the importance of integrating nutritional interventions into disease-specific management pathways, such as for dementia, hip fracture, pressure ulcers, cancer and cystic fibrosis, with clear criteria for initiating, monitoring, and adjusting nutritional support.

The importance of nutritional care and the role of Medical Nutrition are increasingly recognised by government level organisations such as NICE, SIGN, the National Board of Health in Denmark, the Haute Authorité de Santé, France and organisations specialising in specific conditions such as the Clinical Oncology Society of Australia through their condition-specific guidance for healthcare providers and practitioners. This is a critical step in raising the awareness of the issue of malnutrition with specialist healthcare practitioners who otherwise may miss malnutrition and who are ideally placed to recognise the problem early and instigate appropriate nutritional care. In addition, guidance efforts are increasingly aimed not only at acute malnutrition but also at preventing its occurrence in high-risk populations, highlighting the need for proactive screening, early intervention, and multidisciplinary collaboration in both acute and community settings.

A key aspect of many guidance documents is the correct targeting of nutritional intervention, including the use of medical nutrition, at patients who have been identified as malnourished or at risk of malnutrition. It is clear that appropriate use of nutritional intervention is part of the wider task of identifying patients at nutritional risk and implementing timely and appropriate care. There is emerging evidence that screening may reduce the prevalence of malnutrition and that screening programmes, that include intervention and care planning, can contribute to improved outcomes. Ongoing reassessment and personalised adjustment of nutritional interventions are now recognised as essential to maintaining their effectiveness and ensuring they continue to meet patients’ changing needs.

Conclusion

Many national, international, and professional guidelines exist that include medical nutrition as an integral part of patient care. However, continued effort is needed to ensure guidelines are updated to reflect the evidence base, to integrate good nutritional care into guidelines for specific diseases (e.g., nutritional support as part of cancer care guidelines), and to ensure that these guidelines are recognised and established as a credible and essential basis for good patient care. Translation of “academic guidelines” into practical advice for healthcare providers is needed to achieve both improved patient outcomes and to ensure appropriate use of resources. In addition, multidisciplinary collaboration and widespread dissemination of guidelines are critical to promoting adoption in everyday clinical practice, raising awareness of malnutrition risks, and improving the standard of nutritional care across healthcare systems.

Recommendations

On the issue of ONS and ETF as an integrated part of guidelines, the MNI makes the following recommendation:

Examples

Evidence-based guidelines for the nutritional management of patients with a variety of conditions are listed. This list is not exhaustive, and other existing and newly developed national and professional guidelines could extend this overview in the future e.g., relating to PN. Guidelines from around the world have been included if available in English or if an English translation could be obtained.

This unique overview is a starting point which it is hoped will encourage a review of key guidelines and prompt the sharing of information.