46751764

EditorLinda Tapsell, PhD, MHPEd, Dip Nutr Diet, BSc, MAIFST, FDAAWollongong, New South Wales

Acting Supplement EditorIngrid Hickman, PhD, BHSc, APDBrisbane, Queensland

Editorial AssistantKristy ParsonsCanberra, Australian Capital Territory

Prepared by the DAA Malnutrition Guideline Steering CommitteeCheryl Watterson, Grad Dip Nutr Diet, BSc, APDDirector, Nutrition and DieteticsJohn Hunter HospitalNewcastle, New South Wales

Allison Fraser, BHSc, APDResearch and Development DietitianJohn Hunter HospitalNewcastle, New South Wales

Merrilyn Banks, PhD, MHltSc, Grad Dip Nutr Diet, Grad Dip Ed, BSc, APDDirector, Nutrition and DieteticsRoyal Brisbane and Women’s HospitalBrisbane, Queensland

Elisabeth Isenring, PhD, BHSc, AdvAPDNHMRC Australian Clinical Training FellowQueensland University of TechnologyBrisbane, Queensland

Michelle Miller, PhD, MNutDiet, BSc, APDSenior LecturerFlinders UniversityAdelaide, South Australia

Caitlin Silvester, PGrad Dip Diet, Grad Dip HlthSc, BSc, APDDietitianBeechworth Health ServicesBeechworth, Victoria

Roy Hoevenaars, PhD, BSc(Hons), Grad Dip Nutr Diet, BSc, APDManager, Nutrition and DieteticsBarwon HealthGeelong, Victoria

Judy Bauer, PhD, MHSc, GDipNutrDiet, BSc, AdvAPDDirector, Nutrition and DieteticsThe Wesley HospitalBrisbane, Queensland

Angela Vivanti, DHSc, MAppl Sc, Grad Dip Nutr Diet, BSc, AdvAPDResearch & Development DietitianPrincess Alexandra HospitalBrisbane, Queensland

Maree Ferguson, PhD, MBA, Grad Dip Nutr Diet, BAppSc, AdvAPDDirector, Nutrition and DietiticsPrincess Alexandra HospitalBrisbane, Queensland

Nutrition & DieteticsJournal of the Dietitians Association of Australia, including the Journal of the New Zealand Dietetic Association

NDI.JEB.Dec09

SupplementEvidence Based Practice Guidelines for the Nutritional Management of Malnutrition in Adult Patients Across

the Continuum of Care

Journal and Scientifi c Publications Management CommitteeMargaret Allman-Farinelli (Director Responsible)Anthea Magarey (Chairperson)Linda TapsellJudy BauerMarina ReevesGiordana CrossClare CollinsMaree FergusonAndrea BraakhuisJane ElmslieClaire HewatKristy Parsons

Aims and Scope: Nutrition & Dietetics is Australia and New Zealand’s lead-ing peer-reviewed Journal in its fi eld. Covering all aspects of food, nutrition and dietetics, the Journal provides a basic forum for the reporting, discussion and development of scientifi cally credible knowledge related to human nutrition and dietetics.

Widely respected in Australia and around the world, Nutrition & Dietetics publishes original research, review papers, viewpoint articles, insights – short papers on fi ndings from demonstrating practice, letters, book reviews, conference reports and continuing education quizzes.

Abstracting and Indexing Services: The Journal is indexed by Abstracts on Hygiene and Communicable Diseases; Agricola C R I S; Animal Bredding Abstracts; Aquatic Sciences & Fisheries Abstracts; Australasian Medical Index; Australian Family and Society Abstracts; Cumulative Index to Nursing & Allied Health Literature; Dairy Science Abstracts; EBSCO Contentville; Food Science and Technology Abstracts; Horticultural Science Abstracts; Infotrac; Infotrieve; Leisure, Recreation and Tourism Abstracts; Nutrition Abstracts and Reviews; Postharvest News and Information; Potato Abstracts; Poultry Abstracts; Review of Aromative and Medicinal Plants; Rural Development Abstracts; SAGE; Soybean Abstracts; Sugar Industry Abstracts; Tropical Diseases Bulletin; World Agricultural Economics and Rural Sociology Abstracts; World Banking Abstracts; World Magazine Bank.

Address for Editorial Correspondence:Editor, Nutrition & Dietetics1/8 Phipps CloseDeakin ACT 2600AustraliaEmail: [email protected]

Disclaimer: The Publisher, the Dietitians Association of Australia, the New Zealand Dietetic Association, and Editors cannot be held responsible for errors or any consequences arising from the use of information contained in this journal; the views and opinions expressed do not necessarily refl ect those of the Publisher, the Dietitians Association of Australia, the New Zealand Dietetic Association and Editors, neither does the publication of advertisements constitute any endorsement by the Publisher, the Dietitians Association of Australia, the New Zealand Dietetic Association and Editors of the products advertised.

Journal compilation © 2009 (Dietitians Association of Australia).

For submission instructions, subscription and all other information visit www.blackwellpublishing.com/nd

This journal is available online at Wiley Interscience. Visit www.interscience.wiley.com to search the articles and register for table of contents and email alerts.

Access to this journal is available free online within institutions in the devoloping world through the AGORA initiative with the FAO and the HINARI initiative with the WHO. For information, visit www.aginternetwork.org, www.healthinternetwork.org.

ISSN 1446-6368 (Print)ISSN 1747-0080 (Online)

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Nutrition & DieteticsJournal of the Dietitians Association of Australia, including the Journal of the New Zealand Dietetic Association

Volume 66 Supplement 3 December 2009 ISSN 1446-6368

Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of careExecutive summary S1Summary of evidence-based recommendations S2–S3Introduction S4–S10Evidence based statements S11–S20Acknowledgement S21References S22–S27Appendices S28–S34

The Dietitians Association of Australia (DAA) supported the printing of these DAA-endorsed Best Practice Guidelines for the Nutritional Management of Malnutrition in Adult Patients Across the Continuum of Care.

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Evidence based practice guidelines for the nutritionalmanagement of malnutrition in adult patients acrossthe continuum of care

EXECUTIVE SUMMARY

Malnutrition is a major international and Australian healthproblem, which continues to be unrecognised and therefore,untreated. It is both a cause and a consequence of ill healthacross many patient groups and healthcare settings. Malnu-trition interferes with patients’ ability to benefit from healthtreatments and affects every domain of their well-being.Additionally, it increases society’s healthcare costs.

This paper, ‘Evidence based practice guidelines for nutri-tional management of malnutrition in adult patients acrossthe continuum of care’, has been developed to gather thebest available evidence for detecting malnutrition andmanaging it with nutritional interventions.

The Guideline Steering Committee hopes to influencehealth care providers and especially dietitians to increasecapacity within Australia to implement affordable detectionsystems, such as routine malnutrition screening. It isexpected that the guidelines will provide a framework forevidence-based nutritional assessments and increase access

to appropriate patient-focussed treatments for affectedadults that are timely and occur both within and acrosshospital and primary care sectors.

These guidelines are based on an agreed and rigorousprocess undertaken by the Steering Committee, and inaccordance with the Dietitians Association of Australia(DAA) performance standards. They have resulted from thevoluntary contribution of a collaboration of dietitians withclinical and research expertise across a range of practicesettings.

The process involved a systematic search of the literature,an assessment of the strength of the evidence, consultationwith key stakeholders and the development of evidence-based statements and practice tips that may help to guideclinical practice and improve patient experience and healthoutcomes in Australian healthcare sectors for malnourishedadults.

The dissemination and implementation of the recommen-dations of the guidelines will be supported by the DAA.

Nutrition & Dietetics 2009; 66 (Suppl. 3): S1

© 2009 The Author.Journal compilation © 2009 Dietitians Association of Australia

S1

SUMMARY OF EVIDENCE-BASED RECOMMENDATIONS

The guideline recommendations have been graded using the National Health and Medical Research Council (NHMRC)classifications for grades of recommendation1, which are as follows:Level A Body of evidence can be trusted to guide practice.Level B Body of evidence can be trusted to guide practice in most situations.Level C Body of evidence provides some support for recommendation(s) but care should be taken in its application.Level D Body of evidence is weak and recommendation(s) must be applied with caution.

1. Nutrition screening

Clinical question

1a. What is the prevalence of malnutrition and is it a problem?

Evidence-based recommendations

The prevalence of malnutrition is high worldwide (including in Australia) in all healthcare settings, yet is largely under-recognised and under-diagnosed resulting in a decline in nutritional status. Therefore, it is recommended that healthcareprofessionals are informed that malnutrition is associated with adverse clinical outcomes and costs.NHMRC Grade of recommendation: AMalnutrition should be identified, treated and action taken to reduce the prevalence in Australian healthcare settings and incommunity-dwelling adults.NHMRC Grade of recommendation: B

Clinical question

1b. Should there be routine screening for malnutrition and if so where and when should malnutrition screening occur?


Routine screening for malnutrition should occur in the acute setting to improve the identification of malnutrition risk and toallow for nutritional care planning.NHMRC Grade of recommendation: BRoutine screening for malnutrition should occur in the rehabilitation, residential aged care and community settings to improvethe identification of malnutrition risk and enable nutritional care planning.NHMRC Grade of recommendation: D

Clinical question

1c. What screening process can be used to identify adults at risk of malnutrition?


Use a valid malnutrition screening tool appropriate to the population in which it is to be applied.NHMRC Grade of recommendation: B

Nutrition & Dietetics 2009; 66 (Suppl. 3): S2–S3


S2

2. Nutrition assessment

Clinical question

What nutrition assessment processes can be used to diagnose malnutrition in adults?


Use a valid nutrition assessment tool appropriate to the population in which it is to be applied.NHMRC Grade of recommendation: B

3. Nutrition goals, interventions and monitoring

Clinical question

3a. In adults with malnutrition or at risk of malnutrition, what are the appropriate nutrition goals, for optimal client,clinical and cost outcomes?


Aim to prevent decline/improve nutritional status and associated outcomes in adults with malnutrition or at risk ofmalnutrition.NHMRC Grade of recommendation: A

Clinical question

3b. What are the appropriate interventions for prevention and treatment of malnutrition in adults?


Nutrition interventions can improve outcomes. Consideration should be given to the healthcare setting, resources,patient/client goals, requirements and preferences.NHMRC Grade of recommendation: B–C

Clinical question

3c. What are appropriate monitoring and outcome measures to demonstrate improved patient, clinical and costoutcomes?


Choose standardised measures which change in a clinically meaningful way to demonstrate the outcomes of nutritioninterventions.NHMRC Grade of recommendation: not applicable

Practice Guidelines for the Nutritional Management of Malnutrition in Adult Patients Across the Continuum of Care


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1 INTRODUCTION

1.1 Purpose and scope

The purpose of these guidelines is to provide health careprofessionals, especially dietitians with evidence based rec-ommendations supporting the identification and nutri-tional management of malnourished adults. The ‘EvidenceBased Practice Guidelines for Nutritional Management ofMalnutrition in Adult Patients across the Continuum ofCare’ focus on the identification and treatment of malnu-trition in the acute, rehabilitation, residential aged care,and community settings. Although there are other inter-national guidelines which address malnutrition,2,3 it wasdetermined that gaps existed in these guidelines whichwarranted addressing and it was perceived that therewould be a benefit in exploring the evidence base withrespect to the Australian context.

Malnutrition is defined as ‘a state of nutrition in which adeficiency or excess (or imbalance) of energy, protein, andother nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and functionand clinical outcome’.4

For the purpose of these guidelines malnutrition referssolely to protein-energy under-nutrition despite the defi-nition given above which encompasses both under- andover-nutrition.

In developed countries the increasing prevalence ofobesity and its resultant health consequences has contrib-uted to the lack of recognition of under-nutrition. For nutri-tional treatment of obesity the reader is referred to the ‘BestPractice Guidelines for the Treatment of Overweight andObesity in Adults’ endorsed by the Dietitians Association ofAustralia.5

The outcomes of the implementation of these evidencebased guidelines will achieve the following anticipatedbenefits for adults with malnutrition or at risk ofmalnutrition:• Improved access to ethical, effective and efficient patient

care by developing and implementing relevant patient-centred protocols and pathways appropriate to the health-care setting.

• Correct diagnosis of malnourished patients increasingrecognition of the impact of this disease/ condition onpatients and health service.

• Improved patient experience and health outcomes foridentified adults.

• A skilled Dietitian workforce playing a key role in address-ing adult malnutrition across healthcare settings by con-tinuing advocacy of the Dietitians Association of Australia.

• Advocacy for appropriate and adequate food services;eating environments; staff resources and policy.

• Capacity building in Australian health and human ser-vices for preventing, recognising and treating malnutri-tion by the entire health workforce and health policymakers.

1.2 Methods

1.2.1 Guideline framework

In developing these Guidelines the American Dietetic Asso-ciation’s Nutrition Care Process (NCP)6 has been used todefine the clinical questions for the systematic review. TheNCP framework incorporates a standardised process andlanguage as part of a conceptual model to guide and docu-ment nutrition care and patient outcomes.6 The frameworkincludes nutrition assessment, nutrition diagnosis, nutri-tion intervention and nutrition monitoring and evaluation.6

This NCP framework has recently been adopted by theDAA.

A trigger event initiates where and how the patient isidentified for nutrition care.7 This trigger event may includenutrition screening. Since malnourished adults are often notrecognised and thus fail to have access to the Nutrition CareProcess, the ‘trigger event’ has been added to the Guidelineframework. This NCP including the trigger event is illus-trated in Figure 1.7

• Nutrition screening describes the process of identifyingclients with characteristics commonly associated withnutrition problems who may require comprehensivenutrition assessment and may benefit from nutrition inter-vention. These Guidelines refer to malnutrition screeningwhich is used to identify those who may be malnourishedor at risk of malnutrition.

• Nutrition assessment is a comprehensive approach togathering pertinent data in order to define nutritionalstatus and identify nutrition-related problems. The assess-ment often includes patient history, medical diagnosis andtreatment plan; nutrition and medication histories, nutri-tion related physical examination including anthropom-etry, nutritional biochemistry, psychological, social, andenvironmental aspects.

• Nutrition diagnosis is a clinical judgement based on datacollected during the assessment phase. The set of nutritiondiagnoses derived from the assessment data will givedirection to prioritising treatment goals and interventionstrategies. The nutrition diagnosis uses standardised ter-minology which identifies and labels the actual occur-rence, or risk of developing nutrition problems thatdietitians treat independently. A nutrition diagnosis iswritten in PES format that states the problem (P) ornutrition diagnosis, the aetiology (E) or risk factors/causes and the signs and symptoms (S) or measurableadverse nutrition status.8

• Nutrition intervention is designed to address a nutritionproblem or aetiology of the nutrition diagnosis. Nutritioninterventions aim to change nutrition-related behaviour,risk factors, environmental aspects or characteristics ofhealth status.

• Nutrition monitoring is the review and assessment of apatient’s status at a scheduled follow-up point with regardto the nutrition diagnosis, intervention plans/ goals, andoutcomes.


© 2009 The AuthorJournal compilation © 2009 Dietitians Association of Australia

S4

• Outcome evaluation is the systematic comparison ofcurrent findings with previous status, intervention goals,or reference standards. Outcomes which can be used toshow the effectiveness of nutrition interventions can begrouped into direct nutrition outcomes, clinical andhealth status outcomes, patient-centred outcomes, andhealth care utilisation and cost outcomes.9

1.2.2 Literature appraisal and collation

Developing the literature search strategy and clinical questionsRelevant clinical questions were developed for componentsof the Nutrition Care Process (Figure 1). A systematic litera-ture review of studies was designed to address the clinicalquestions using appropriate search terms and methodolo-gies. Three searches were written for the Medline Databaseusing the OVID search engine and then modified to suitEmbase and CINAHL databases. The Cochrane Database ofSystematic Reviews was searched for all papers relating tomalnutrition. The searches were limited to the English lan-guage and studies involving humans. Limits were addedwhich excluded tutorials, editorials, news, letters and com-ments. Articles not reported in full (abstract only) were alsoexcluded. Preliminary inclusion and exclusion criteria weredefined by agreement of the Steering Committee andincluded in the search methodology where applicable. Pleaserefer to Appendix 1 for the detailed search strategy. Theclinical questions were as follows:

1. Criteria for screening and referral systems (Figure 1):What is the best method for identification of adults withmalnutrition or at risk of malnutrition for improvedpatient, clinical and cost outcomes?

2. Nutrition assessment (and Nutrition Diagnosis)(Figure 1):Which specific measures best reflect nutritional status orchange in nutritional status in adults with malnutrition orat risk of malnutrition, for the diagnosis of malnutrition,can be altered by nutritional intervention, and are asso-ciated with improved patient, clinical and cost outcomes?

3. Nutrition intervention; Nutrition monitoring andevaluation (Figure 1):a) What are the nutrition goals for adults with malnutri-

tion or at risk of malnutrition for improved patient,clinical and cost outcomes?

b) In adults with malnutrition or at risk of malnutrition,what are the appropriate nutrition interventions, tooptimise nutritional status for improved patient,clinical and cost outcomes?

c) In adults with malnutrition or at risk of malnutrition,how will nutrition interventions be monitored forimproved patient, clinical and cost outcomes?

All searches were conducted to August 2006. For the firsttwo clinical questions databases were searched from incep-tion of the databases whereas the final question (Q3) wasfrom 1996. The searches returned a total of 3987 titles andabstracts for review. In response to the large number of

Social Systems

Code of Ethics

Comm

unicat

ion

Collaboration

Screening & Referral System • Identify risk factors

• Use appropriate tools and methods • Involve interdisciplinary collaboration

The Nutrition Care Process

Nutrition Assessment& Re-assessment

Nutrition Diagnosis• Identify & label problem

• Determine cause/contributing

risk factors• Cluster signs & symptoms/defining characteristics• Document

Relationship BetweenPatient/Client/Group

& Dietetics Professional

NutritionMonitoring & Evaluation

• Monitor progress• Measure outcome indicators• Evaluate outcomes• Document

Nutrition Intervention• Plan nutrition intervention • Formulate goals & determine a plan of action• Implement nutrition intervention • Care is delivered & actions are carried out• Document

Outcomes Management System • Monitor the success of the Nutrition Care Process Implementation

• Evaluate the impact with aggregate date • Identify and analyze causes of less than optimal performance and outcomes

• Refine the use of the Nutrition Care Process

Practice Settings

Eco

no

mic

s

Health

Care S

ystems

Dietetics Knowledge

Evid

ence

-base

d Pra

ctice

Skills

& C

om

pete

ncie

s

Critical Thinking

• Obtain/collect timely &

appropriate data

• Analyze/interpret with evidence-based standards

• Document

Figure 1 American Dietetic Association Nutrition Care Process and Model7. Reproduced with the permission of Elsevier.



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abstracts retrieved, the Steering Committee made somemodifications to manage the literature appraisal as follows:

The search for the nutrition screening tool section wasmodified to focus on the main recommendations from theJones review in 200610 of 44 nutrition screening and assess-ment tools describing literature until the year 2000 and alsoany identified relevant articles of screening tools with levelIII-2 evidence or higher to support their use published after2000. Ninety-six articles were identified published betweenJanuary 2000 and November 2008.

Since August 2006 modifications have been made to theclinical questions. A newly devised question has been addedto determine whether malnutrition is a problem in Australia(prevalence) and question 1 has been split into parts toenhance the focus of the evidence based statements. Diag-nosis was removed from the clinical questions when theInternational Statistical Classification of Diseases andRelated Health Problems 10th Revision Australian Modifica-tion (ICD-10-AM) criteria for diagnosing malnutrition wasreleased.11 Consequently the new ICD-10-AM diagnosticcriteria for malnutrition has been included in the documentas a Nutrition Assessment practice tip. Please refer toTable 1 for the final clinical questions.

For question 1a evidence was extracted from Stratton’scomprehensive review of studies until 2003 investigating the

prevalence and consequences of malnutrition.12 A literaturesearch was then conducted to identify international reviewsbetween 2003 and 2008 as well as all published paperswhich investigated malnutrition prevalence in an Australianor New Zealand population.

The literature identified in the searches for the initialclinical questions along with the literature attained from theadditional clinical question (question 1a) was then appraisedfor the guidelines. Seventy-eight papers (including the Strat-ton review) met the inclusion criteria (refer to Table 2) forquestion 1a and b.12 In addition to the Jones 2006 review,10

41 papers published between January 2000 and November2008 met the inclusion criteria for the screening tool part ofthe question (question 1c). For question 2, twenty-five

Table 1 Final Guideline clinical questions

Nutrition CareProcess

Clinical questions whichinformed the systematic

search

NutritionScreening

Q1a) What is the prevalence ofmalnutrition and is it a problem?1b) Should there be routinescreening for malnutrition and if sowhere and when shouldmalnutrition risk screening occur?1c) What screening process can beused to identify adults at risk ofmalnutrition?

NutritionAssessment andNutritiondiagnosis

Q2. What nutrition assessmentprocesses can be used to identifymalnutrition in adults?

Nutrition goals (a) Q3a) In adults with malnutrition orat risk of malnutrition, what are theappropriate nutrition goals, foroptimal client, clinical and costoutcomes?

Nutritioninterventions (b)

Q3b) What are the appropriatenutrition interventions forprevention and treatment ofmalnutrition in adults?

Nutritionmonitoring andevaluation (c)

Q3c) What are appropriatemonitoring and outcome measuresto demonstrate improved patient,clinical and cost outcomes?

Table 2 Inclusion and Exclusion Criteria

Inclusion criteria Exclusion criteria

Protein-energy malnutrition Non-English languageUndernutrition Children/ PaediatricsEnergy deficiency Specific Vitamin Deficiencies

(e.g. Vitamin D)Protein deficiency Specific Mineral Deficiencies

(e.g. Magnesium)Adults Eating Disorders (anorexia or

bulimia)Medical Nutrition Therapy Cystic FibrosisMeasurements of Nutrition

Status (eg biochemistry,anthropometry)

Coeliac Disease

Screening forProtein-EnergyMalnutrition

Obesity surgery (Gastricbypass/ bands)

Assessments of Nutritionstatus (e.g. Assessmenttools)

Liver Disease

Nutrient intakes Renal disease and ChronicKidney Disease

Nutrition interventions(a) Dialysis and HaemodialysisNutrition monitoring Hereditary protein deficiency

disordersComplications, mortality

and morbidity relating tomalnutrition

Non-Systematic reviews/opinions/viewpoints

Unspecified nutritionaldeficiency

Non-Western Countries

Critical care Crohns DiseaseAlcoholism Alcoholism if malnutrition is

vitamin relatedPrevalence data only CancerScreening tools with �2

parameters for thescreening section only

HIV

(a) Note: if nutrition interventions included an exercise component,these studies were included in the guidelines, however pharmaceu-tical interventions are not specifically addressed in these Guidelines.HIV, Human Immunodeficiency Virus.



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papers were assessed as meeting the inclusion criteria andincluded an assessment tool measured against a means ofconfirming validity. One hundred and four papers wereassessed as meeting the inclusion criteria for question 3and retrieved for full appraisal. Thus, a total of 249 paperswere reviewed for the guidelines.

A minimum of two Steering Committee members inde-pendently assessed the titles and abstracts using the inclu-sion and exclusion criteria (Table 2) before retrieving the fullarticle. Criteria were added when the reviewers commencedassessing the literature and determined further criteria wereneeded to ensure the scope of the guidelines remainedfocussed. Additional criteria exclude conditions and diseaseswhich were already the subject of other DAA evidence basedguidelines or were alternate, potentially co-existing mecha-nisms for protein-energy malnutrition such as sarcopenia orcachexia (please refer to existing DAA endorsed evidencebased practice guidelines: Evidence Based Practice Guide-lines for Nutritional Management of Patients ReceivingRadiation Therapy,13 Cancer Cachexia,14 Chronic KidneyDisease,15 and Australasian Clinical Practice Guideline forNutrition in Cystic Fibrosis.16)

Tables were developed to collate the evidence for screen-ing, assessment, intervention, monitoring and evaluation.Evidence was categorised by health care setting and patientcharacteristics as described in Table 3.

1.2.3 Rating the evidence

The strength of the evidence was assessed using the level ofevidence rating system recommended by the ‘NationalHealth and Medical Research Council (NHMRC) additionallevels of evidence and grades of recommendations for devel-opers of guidelines-Pilot Program’ (Appendix 2).1 NHMRClevel of evidence of rating scheme is provided for varioustypes of studies including: intervention; diagnosis; pro-gnosis; aetiology; and screening (Appendix 2).• Aetiology study criteria were used for clinical questions 1a

and 1b• Diagnostic studies were used for clinical questions 1c and 2• Intervention studies were used for clinical questions 3 a), b)

&c)In all cases the evidence was ranked by two independent

reviewers. Any disagreements between reviewers werehandled by a third independent reviewer. This evidence theninformed the evidence based statements.

Only articles assessed as providing the highest level ofevidence were included in the evidence based statements.However, with respect to the evidence base in the Australianand New Zealand populations, this evidence is also pre-sented, where available, in addition to the higher level evi-dence from international studies. Unfortunately no NewZealand studies were located. This approach was supportedby Dietitian stakeholder consultation in May 2008. Articlesidentified to be the same level of evidence but reportinginconclusive findings have been noted. Articles wereexcluded if they reported inconclusive findings and werereviewed as being of a lower level of evidence than articles

supporting the evidence based statement. Some articles wereassigned two levels of evidence. This was to demonstrate thedifference between findings generated from analyses per-formed within (Level IV) and between group (Level II-III-3).If no evidence was returned during the search this wasidentified as ‘no evidence located’ in the evidence basedstatements.

The grades of recommendations were then formulatedfrom the evidence based statements. The five componentsthat are considered in judging the body of evidence to applya grade of recommendation according to the NHMRC clas-sification are the volume of evidence, consistency of theresults, potential clinical impact of the proposed recommen-dation, and the generalisability of the body of evidence to theAustralian health care context (Appendix 2).1

The grades of recommendation are:Level A Body of evidence can be trusted to guide practice.Level B Body of evidence can be trusted to guide practice

in most situations.Level C Body of evidence provides some support for

recommendation(s) but care should be taken inits application.

Table 3 Definitions used for collating evidence basedstatements

Setting/ DemographicDefinition for the purpose of collating

the evidence based statements

Acute Care Acute Care is defined as servicesoccurring within an acute carehospital

Rehabilitation Rehabilitation is defined as servicesby a multidisciplinary team withthe goal of reducing disability byimproving task-orientedbehaviour.17 Rehabilitationsettings include both inpatientand ambulatory settings.

Residential AgedCare

Residential Aged Care is defined asservices for aged people who canno longer be assisted to stay intheir home.18 Residential agedcare settings involve both low(hostel) and high care (nursinghome).

Community Community is defined as free livingadults with or without assistancefrom community services.

Across settings Across settings is used to describeevidence which involvedparticipants or analysis in two ormore of the above settings.

Older adult Groups of study participants had amean age over 60 years.

Note: Literature describing the setting as ‘sub-acute’ was reviewedclosely and reported according to the setting for which the partici-pants were most aligned. In most cases these were the acute andrehabilitation settings.



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Level D Body of evidence is weak and recommendation(s)must be applied with caution.

A process of decision making to deal with any conflictarising between members of the Steering Committee wasagreed upon. If one or more Steering Committee memberswere in disagreement with the majority then these Commit-tee members were requested to seek additional informationto support their position. If the conflict was unable to beresolved at this point then the process was for the SteeringCommittee to seek advice from an independent expert.

1.2.4 Development of the practice tips

Whilst evidence based statements are objective interpreta-tions of available evidence, ‘practice tips’ were developed bythe Committee where there was insufficient high level evi-dence from the literature to support an evidence based state-ment, but enough low level evidence and/or ‘expert opinion’to provide a statement of support for a practice approach.

The practice tips contained within these Guidelinesacknowledge the diversity of settings and age related targetgroups and are often an extension to relevant evidence basedstatements in order to provide further detail or clarification.

In all cases, the practice tips have required consensus byall members of the Committee and external reviewers.

The Committee also recommends that evidence basedrecommendations and practice tips contained in this docu-ment are read in conjunction with relevant complementaryguidelines. Some examples include the National Institute forHealth and Clinical Excellence (NICE) Nutrition support inadults,3 European Society of Parenteral and Enteral Nutrition(ESPEN) guidelines on adult enteral nutrition19 and thestroke guidelines.20,21 The development process for theseother Guidelines allowed recommendations based on bothformal and informal consensus methods using expertopinion when there was an absence of scientific literature.

1.3 Consultation process

At the DAA 26th National Conference in 2008, a formativeconsultation with dietitians was sought on: relevant content,ease of use, clarity of recommendations, organisationalbarriers and whether or not these guidelines would be usedin practice.

The feedback provided by the ninety five participantsindicated that the majority of dietitians understood theGuideline development process; found that the Guidelineformat and structure were easy to follow; that the overallobjectives were clear and that the evidence based recommen-dations were specific and unambiguous. Participantsstrongly agreed that they would use the Guidelines as part oftheir everyday practice. Most agreed that the Guidelineswould help to bridge the gap between research and practiceand that the Guidelines would result in the anticipatedbenefits claimed.

Specific feedback on improvements to the document wereconsidered by the Committee and incorporated as appropri-ate. For example, a range of DAA endorsed evidence based

practice guidelines, were reviewed and cross referenced withthe current document where relevant. These included; Evi-dence based practice guidelines for nutritional managementof radiation therapy,13 cancer cachexia,14 chronic kidney dis-ease15 and cystic fibrosis.16 The Committee decided that itwas also important to include information on disease statessuch as cancer, renal disease and (Human Immunodefi-ciency Virus/ Acquired Immune Deficiency Syndrome ) HIV/AIDS in order to answer question 1a. ‘What is the prevalenceof malnutrition and is it a problem?’. However, these diseasesare not referred to in later questions; instead reference ismade to the above guidelines.

Further, where participants identified gaps in the litera-ture in the intervention section, additional studies werelocated including studies published after the final date ofthe systematic search.

A list of barriers to the implementation of the Guidelinesin workplaces across the continuum of care were identifiedby workshop participants in 2008. Another workshop washeld at the DAA 27th National Conference in 2009 whichfocussed on addressing the barriers to implementation pre-viously identified. This body of work is discussed underApplicability.

As part of the DAA guideline development process, theseGuidelines have been independently reviewed by expertsand assessed using the Appraisal of Guidelines for Researchand Evaluation (AGREE) instrument.22 Modifications tothese Guidelines have been undertaken in response to thisreview.

Since the Steering Committee acknowledge that dietitiansdo not act alone in either the detection or treatment ofmalnourished patients, it was considered important toconsult with a wide range of health professionals andconsumers of health services. The March 2008 versionwas circulated by DAA on behalf of the Steering Committeefor multidisciplinary feedback to a range of organisationsincluding:Aged Care Association Australia (ACAA)Australasian Podiatry CouncilAustralian Association for Exercise and Sports ScienceAustralian Association of GerontologyAustralian Association for Quality in Health Care (AAQHC)Australian Association of Occupational TherapistsAustralian Association of Social WorkersAustralian General Practice NetworkAustralian Physiotherapy AssociationAustralian Psychology SocietyAustralian College of Health Service Executives (ACHSE)Australian Meals On WheelsAustralian New Zealand Society for Geriatric MedicineInstitute of Hospitality in HealthcareRoyal College of Nursing AustraliaServices for Australian Rural and Remote Allied Health

(SARRAH)Services for Australian Rural and Remote Allied HealthSociety of Hospital Pharmacists of AustraliaSpeech Pathology AustraliaThe Royal Australasian College of Physicians



S8

The Steering Committee sought comments from the aboveorganisations regarding identification of relevant outcomes,target audiences, format for different users, obstaclesto implementation, and formulation of implementationstrategies.

Unfortunately, despite the request for feedback from sometwenty organisations, including two patient advocacygroups, feedback was received from only three organisations:Speech Pathology Australia; Royal College of NursingAustralia; and the Australian New Zealand Society forGeriatric Medicine. All feedback was discussed by theSteering Committee and incorporated into this final versionof the guidelines where appropriate.

Further engagement with stakeholders will be undertakenas part of the launch by DAA of these guidelines and a formalstakeholder consultation will be incorporated into the stra-tegic review plan.

1.4 Review process

The Guideline review process will be undertaken by theestablishment of an implementation committee. The role ofthis committee will be to regularly review the evidence baseand recommendations for practice. The implementationcommittee will establish an implementation and evaluationstrategic plan in association with DAA. One focus will be toevaluate the contribution of the Guidelines towards achiev-ing the anticipated benefits listed at the front of the docu-ment. Another will be increasing awareness of this healthissue and participation amongst stakeholders includingpatients in implementing sustainable practice change.

This will be accomplished by converting these guidelinesto a living document by using the Wiki format (refer tohttp://wiki.org for further information). This will allowongoing comment by the target audience and timely revisionof the document based on new evidence by the implemen-tation committee. It is anticipated that at least bi-annualreview will occur.

The workshops conducted in 2008 and 2009 have alsobegun the evaluative phase of the guidelines and will con-tinue as a result of the national guideline disseminationprocess.

1.5 Applicability

Although, these Guidelines provide the best available evi-dence and a framework to aid clinical decision making, theydo not replace health professionals’ responsibility to makedecisions appropriate to the circumstances of the individualpatient. Malnutrition identification and treatment processesmust conform with ethical and legal requirements. The bestinterests of the patient should be paramount; this includes aconsideration of the risks and benefits of identifying andtreating malnutrition for the individual patient. Treatmentmust be undertaken with the informed consent of the patientor carer.3

Nutrition support management should be individualisedand include the patient’s preferences and allow for commu-

nication difficulties or cognitive impairments. In addition,it needs to be culturally appropriate, comprehensive, andcoordinated across all relevant disciplines and settings.

The goals and outcomes of nutrition intervention will bedependent on the diagnosis and prognosis of the person.Patients need to be managed in the context of theirco-morbidities. The benefits and risks including potentialadverse effects of any nutrition treatment such as risk ofswallowing impairment need to be assessed and explainedto the individual patient.3

For persons with end-stage disease the desired outcome ofnutritional management is to maximise patient comfort andquality of life. The publication, Guidelines for a PalliativeApproach in Residential Aged Care23 may help inform healthprofessional decision making around physical symptomassessment and management for patients with end-stagedisease.

Putting evidence into practice is difficult.24 For theseGuidelines to have an effect on reducing the burden ofmalnutrition on the Australian population there needs to aneffective dissemination and implementation strategy.

Innovations require one or more health professionals tolead, support and drive them through. Dietitians are ideallyplaced to act as clinical lead in applying this Guideline acrossAustralian healthcare settings. Clinical coordinators are rec-ognised as amongst the most effective implementation strat-egies.25 Practice change strategies coordinated by dietitian coinvestigators have been shown to lead to successful imple-mentation of an evidence based guideline in a complexAustralian healthcare setting.26

Also the DAA Board is committed to an active role indisseminating the Guideline by publication and to holdingcontinuing professional development activities (‘roadshows’) around Australia to which all stakeholders will beinvited. The DAA website, www.daa.asn.au will provide alink to the Guideline in both the members section (DINER)and a webpage available to non-members.

National dissemination will support Dietitians to developskills in organising screening pathways and using valid assess-ment tools. The DAA website will also link members withrelevant implementation resources.27,28 The new NationalCompetency Standards for Entry Level Dietitians in Austra-lia29 now include performance criteria which support knowl-edge and skills in nutrition screening and assessment tools.

National workshops conducted in 2008 and 2009 haveresulted in participants identifying barriers and discussingsolutions to overcoming these barriers (enablers) using theNational Institute of Clinical Studies (NICS) barrier tool.30

Barriers typically included time, skills, knowledge andorganisational agenda. Recognition of the importance ofaddressing malnutrition in a health setting together withstaff/colleague willingness to prioritise management ofmalnutrition is a necessity for successful implementation.

1.6 Editorial Independence

The Guidelines were developed without the assistanceof commercial sponsorship. As highlighted in the



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Acknowledgements section of these guidelines, somefunding was provided by both Hunter New England Popu-lation Health (Steering Committee Research Officer to deviseand conduct a systematic review of the literature) and DAA(funded one face to face Steering Committee Meeting). In

kind support was provided by the employers of the SteeringGroup. To ensure integrity of the recommendations in theseguidelines, Steering Committee members who were alsoauthors of an article being reviewed were removed fromthe process of evaluating the article for levels of evidence.



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EVIDENCE BASED STATEMENTS

1. Nutrition Screening

Clinical question

1a: What is the prevalence of malnutrition and is it a problem?

Evidence StatementLevel of Evidence (using

Aetiology criteria—Appendix 1)

There is a high prevalence of malnutrition in the:Acute care setting (in the order of 20–50%) Level l12,31

Level ll32–34 [Aus]

Level IV35–37 [Aus]

Rehabilitation setting (in the order of 30–50%) Level l12

Level II32,38–40 [Aus]

Residential aged care setting (in the order of 40–70%) Level l12

Level IV35,41

Community setting (in the order of 10–30%) Level l12

Level IV42,43 [Aus]

The prevalence of malnutrition is higher in certain groups of individuals eg. in older adults; and in certain diseasestates:

Older adults Level l12

Level IV35 [Aus]

Cancer Level l12

Level IV35 [Aus]

Critical illness Level l12

Level IV35 [Aus]

Neurological disease Level l12

Orthopaedic injury Level l12

Level IV44 [Aus]

Respiratory disease Level l12

Level IV45 [Aus]

Gastrointestinal and liver disease Level l12

Renal disease Level l12

HIV and AIDS Level l12

Malnutrition is associated with adverse clinical outcomes and costs in the:Acute care setting Level l12

Rehabilitation setting Level II38–40 [Aus] 46,47

Residential aged care setting Level II48

Community setting Level l12

Level II43 [Aus]

Malnutrition is under-recognised and under-diagnosed in the:Acute care setting Level I12,49

Level IV36,37 [Aus]

Rehabilitation setting Level l12

Level II39 [Aus]

Residential aged care setting Level l12,49

Level lV50 [Aus]

Community setting Level I12,49

Identification, documentation and coding of malnutrition results in a favourable reimbursement under casemixfunding in the:

Acute care setting Level II33 [Aus], 51–53

Other settings Not applicable



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Nutritional status deteriorates in a significant proportion of individuals over the course of admission in the:Acute care setting Level II54–58

Rehabilitation setting Level II59 [Aus]

Residential aged care setting No evidence locatedCommunity setting No evidence locatedRecommendationsThe prevalence of malnutrition is high worldwide (including in Australia) in all healthcare settings, yet is largely

under-recognised and under-diagnosed resulting in a decline in nutritional status. Therefore, it is recommended thathealthcare professionals are informed that malnutrition is associated with adverse clinical outcomes and costs.

NHMRC Grade of recommendation: AMalnutrition should be identified, treated, and action taken to reduce the prevalence in Australian healthcare settings, and

in community dwelling adults.NHMRC Grade of recommendation: B

Clinical question

1b: Should there be routine screening for malnutrition and if so where and when should malnutrition screeningoccur?

Evidence StatementLevel of Evidence (using Aetiology

criteria—Appendix 1)

Implementation of malnutrition risk screening programs improves the identification of individuals at risk ofmalnutrition.

Acute care setting Level II52,60

Rehabilitation setting No evidence locatedResidential aged care setting No evidence locatedCommunity setting Level lV61

Implementation of routine malnutrition risk screening facilitates timely and appropriate referral for nutrition carein settings.

Acute setting Level II60,62,63

Rehabilitation setting No evidence locatedResidential aged care setting No evidence locatedCommunity setting Level lV61

There is no available evidence to determine the required frequency of routine malnutrition screening acrosssettings.

Across all settings No evidence locatedRecommendationsRoutine screening for malnutrition should occur in the acute setting to improve the identification of malnutrition risk and

to allow for nutritional care planning.NHMRC Grade of recommendation: BRoutine screening for malnutrition should occur in the rehabilitation, residential aged care and community setting to

improve the identification of malnutrition risk and enable nutritional care planning.NHMRC Grade of recommendation: D

Clinical question

1c: What screening process can be used to identify adults at risk of malnutrition?

Evidence Based StatementLevel of Evidence (using Diagnostic

criteria—Appendix 1)

In the acute care setting, valid malnutrition screening tools include:Malnutrition Screening Tool (MST)64 [Aus] Level II65

Level III-264 [Aus]

Malnutrition Universal Screening Tool (MUST)66 Level III-266–70

Mini Nutritional Assessment-Short Form (MNA-SF)71 older adults only Level III-172

Nutritional Risk Screening (NRS-2002)73 Level III-268,69,73

Simplified Nutritional Assessment Questionnaire (SNAQ(c))62 Level II65



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In the rehabilitation setting, valid malnutrition screening tools include:MNA-SF71 Level III-274 [Aus], 71

Rapid Screen40 [Aus] Level II40 [Aus]

In the residential aged care setting, valid malnutrition screening tools include:MNA-SF71 older adults only Level III-271,75,76

MUST66 Level III-277

Simplified Nutritional Appetite Questionnairec (SNAQ)78 Level III-278

Simple Nutrition Screening Tool79,80 Level III-279,80

In the community setting, valid malnutrition screening tools include:MNA-SF71 older adults only Level III-271,75

MUST66 Level III-266

Seniors in the Community: Risk Evaluation for Eating and Nutrition(SCREEN II)81 older adults only

Level III-181

SNAQ78 (a) Level III-278

SNAQ(c)62 Level II82

RecommendationUse a valid malnutrition screening tool appropriate to the population in which it is to be applied.NHMRC Grade of recommendation: Ba NB: there are two different screening tools called SNAQ; one developed in the USA78 and one developed in the Netherlands.62

Malnutrition Screening Practice Tips:

1a.i. Determination of malnutrition prevalence – conduct a single day survey of the nutritional status of a majority ofpatients, residents or clients in your setting using a validated nutrition assessment tool (refer to Question 2). Prevalenceof malnutrition = number of malnourished patients/total number of patients assessed.

1a.ii. In the acute setting, consider determination of potential reimbursement of coding for malnutrition under casemixfunding.33 Refer to Nutrition Assessment practice tip 2.iii.

1a.iii. Reasons to exclude certain patient groups from malnutrition screening include: groups with low risk of malnutrition e.g.obstetric patients, who are unlikely to benefit from intervention; or very high risk of malnutrition e.g. head and neckcancer patients requiring mandatory referral for nutritional intervention.13,49

1b.i. Malnutrition screening could be performed by people who come into contact with all individuals at risk of malnutritionsuch as nursing staff, assistants, administrative staff, doctors or directly by patients/ carers themselves. Who performsmalnutrition screening may be dependent on the setting or specific facility e.g. dietetic assistants may conduct screeningin rural facilities, whereas nursing staff may do this in tertiary hospitals.64

1b.ii. The malnutrition screen should be incorporated into standard processes e.g. admission forms, patient informationsheets or residential aged care forms.49

1b.iii. Repeat malnutrition screening for those initially screened as at low risk. Due to lack of studies, there are noevidence-based statements regarding the frequency of nutrition screening, but examples of recommended screeningfrequency include: ideally rescreening weekly in hospital or rehabilitation 3 monthly in residential aged care settings,83

and annually in the community setting (perhaps by GP, practice nurse, MOW, HACC), or more frequently where thereis clinical concern.42,84

1c.i. Select a valid malnutrition screening tool for your setting. Most of the valid malnutrition screening tools contain similarparameters. Some tools are very similar e.g. Rapid Screen40 and Simple Nutrition Screening tool79,80 both consist of BodyMass Index (BMI) and percentage weight loss. Key considerations for choice of a screening tool include: who will beundertaking the screening e.g. skill level, time to undertake; and burden of completion e.g. number of questions,measurements, equipment and calculations that may be required (refer to Appendix 3). For example; to determine BMIrequires equipment for measurements, a certain level of skill to undertake the measurements and calculation of theactual BMI, which may result in the tool not being completed correctly.85 For calculation of BMI in older adults, anappropriate alternative method for estimating standing height is to measure knee height according to standard protocoland using purpose specific equipment.86

1c.ii. A scored malnutrition screening tool can help with workload management issues by prioritising those patients with thegreatest need for nutrition support.64

1c.iii. Single parameters, such as Corrected Arm Muscle Area (CAMA), BMI and albumin, have some evidence of predictivevalidity87–90 however, screening tools with at least two parameters are recommended because there is evidence that theyhave higher sensitivity and specificity at predicting nutritional status.



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1c.iv. For patients identified as at risk of malnutrition, a process for assessment, intervention and monitoring needs to be putin place appropriate to the setting. It is important to regularly audit compliance with nutrition screening processes andaddress identified barriers.

1c.v. If the client has been referred to a dietitian by direct methods e.g. medical referral, nutrition screening isunnecessary—proceed directly to nutrition assessment and intervention.

For details of screening tools validated in cancer and chronic kidney disease refer to the DAA endorsed guidelines by Isenringet al. 2008,13 Bauer et al. 200614 and Australia and New Zealand Renal Guidelines Taskforce.15

2. Nutrition Assessment

Clinical question

What nutrition assessment processes can be used to diagnose malnutrition in adults?

Evidence Based StatementLevel of Evidence (using

Diagnostic criteria—Appendix 1)

In the acute care setting valid nutrition assessment tools include:Subjective global assessment (SGA)91 Level III-192,93

—all adults Level III-294–96

Mini-nutritional assessment (MNA)97 (a) Level III-275,95,98–101

—undertaken in older adults onlyPatient generated subjective global assessment (PG-SGA)102 Level III-2103 (b) [Aus]

—all adults

In the rehabilitation setting valid nutrition assessment tools include:Subjective global assessment (SGA) Level II104

—undertaken in older adults onlyMini-nutritional assessment (MNA) Level III-239,47,105 (b)

—undertaken in older adults only

In the residential aged care setting valid nutrition assessment tools include:Subjective global assessment (SGA) Level III-248 (b)

—undertaken in older adults onlyMini-nutritional assessment (MNA) Level III-275,98,105,106


In the community setting valid nutrition assessment tools include:Subjective global assessment (SGA) Level III-2107

—undertaken in older adults onlyMini-nutritional assessment (MNA) Level III-243 [Aus], 108 (b), 107,75,101 (b)


RecommendationUse a valid nutrition assessment tool appropriate to the population in which it is to be applied.NHMRC Grade of recommendation: B(a) Any modified versions of the MNA, SGA and PG-SGA (including cutoffs) cannot be assumed as validated until evaluated across a range ofsettings, against recognised nutrition assessment parameters, with adequate power.(b) Level of Evidence assessed using predictive (but not clinical) validity.

Nutrition Assessment Practice Tips:

2. Select a valid nutrition assessment tool for diagnosing protein-energy malnutrition which meets the needs of yoursetting, ideally across all patient/ client groups.

2.i. Training is required for the correct application of nutrition assessment tools.2.ii. Nutrition assessment may not always be able to be completed immediately and more information may need to be sought,

for example; from families of patients with communication or cognition difficulties, or from interpreters for non-Englishspeaking patients, or by direct observation of food intake, before a diagnosis of malnutrition can be made. However thisshould not preclude commencing a nutrition intervention.



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2.iii. To diagnose malnutrition, use the ICD-10-AM Sixth Edition11 criteria (see Appendix 3):E43 Unspecified severe protein energy malnutritionIn adults, BMI < 18.5 kg/m2 or unintentional loss of weight (�10%) with evidence of suboptimal intake resulting insevere loss of subcutaneous fat and/or severe muscle wasting.E44 Protein-energy malnutrition of moderate and mild degreeIn adults, BMI < 18.5 kg/m2 or unintentional loss of weight (5–9%) with evidence of suboptimal intake resulting inmoderate loss of subcutaneous fat and /or moderate muscle wasting.In adults, BMI < 18.5 kg/m2 or unintentional loss of weight (5–9%) with evidence of suboptimal intake resulting in mildloss of subcutaneous fat and/or mild muscle wasting.Amendments were made to the criteria for diagnosis of malnutrition in ICD-10-AM Sixth Edition (July 2008). In theacute care setting, clinical coders will now assign the appropriate code for malnutrition if there is adequate documen-tation by a dietitian. Consequently, dietitians need to ensure that nutrition documentation meets the diagnostic criteria.It is important to liaise with clinical coders in the acute care setting to discuss how the organisation’s documentationmeets the diagnostic criteria. A malnutrition sticker may be useful to help identify patients to coders and standardisedietetic practice.In several Australian states in acute care facilities, assignment of the correct malnutrition code in some cases may increasethe complexity and comorbidity level and thus, alter the Diagnosis Related Group and increase the casemix fundingto the facility.

2.iv. The inclusion of BMI < 18.5 kg/m2 is based on World Health Organisation (WHO) criteria. However, in all settingsclients with a higher BMI may be malnourished. There is evidence to suggest that weight loss of 5% annually is predictiveof poor outcomes in older adults in acute and community settings.88,109,110 The mini nutritional assessment (MNA)acknowledges a higher BMI cut off for older adults.97 Unintentional weight loss is a better predictor of malnutrition thana weight or BMI at a single time point. For weight loss, a timeframe of 3 to 6 months is the consensus opinion,3 howeverclinical professional judgement should be used.

2.v. Single parameters have some evidence of predictive validity for nutrition assessment, however the same limitations applyhere as for malnutrition screening (see practice point 1c.iii.). Valid assessment tools are recommended because they havehigher sensitivity and specificity at predicting nutritional status.

2.vi. Subjective Global Assessment (SGA) and PG-SGA have previously been identified as valid methods of assessingnutritional status in patients as determined by levels of evidence in DAA Evidence Based Practice Guidelines forNutrition Management Cancer Cachexia (SGA and PGSGA), Patients Receiving Radiation Therapy (SGA and PGSGA)and Chronic Kidney Disease (SGA).13–15

2.vii. During nutritional assessment, as well as collecting pertinent data for diagnosing malnutrition, make sure to collect dataon the aetiology or contributing causes of the low BMI, unintentional weight loss, and/or poor intake. These may includephysiological causes such as altered nutrient need, malabsorption, Dysphagia, socio-economic causes such as lack ofaccess to food, poor nutrition related knowledge, and psychological causes such as depression, dementia, and/or eatingdisorder. These causes of malnutrition are identified to inform the nutrition care process.8,9

3. Nutrition Goals, Interventions and Monitoring

Clinical question

3a: In adults with malnutrition or at risk of malnutrition, what are the appropriate nutrition goals, for optimalclient, clinical and cost outcomes?

Evidence StatementLevel of Evidence (using Intervention

criteria—Appendix level 1)

In all settings improved outcomes may be achieved by establishing nutrition goals which focus on:Prevention of decline in nutritional status and associated adverse

outcomes such as increased complications, including infections;incidence of pressure ulcer formation and mortality.

Level I3,111–114

Optimising nutritional status and other health outcomes byimproving total nutrient intake and body anthropometry incollaboration with the multidisciplinary team by timelyinterventions which are appropriate to the patients needs.

Level I3,112,115,116

RecommendationAim to prevent decline/ improve nutritional status and associated outcomes in adults with malnutrition or at risk of

malnutrition.NHMRC Grade of recommendation: A



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Clinical question

3b: What are the appropriate interventions for prevention and treatment of malnutrition in adults?

Setting Outcome(a) Level of evidence

Modifications to food provision methods(b) may improve outcomes including:Acute care Energy intake and weight status117 Level II

Global nutritional status118 Level III-3Rehabilitation Energy intake119 Level II

Protein intake119 Level III-2Residential aged care Fluid intake120 Level II

Energy and protein intake;121,122 weight status;123 physical function;123

quality of life; 123 and global nutritional status121Level III-1

Community Weight status124 Level III-2Global nutritional status125 Level IV

NHMRC Grade of recommendation: B

Feeding support provided by health care assistants may improve outcomes including:Acute care Energy intake;126 body composition;126 use of antibiotics127 and life

expectancy126Level II

Rehabilitation No evidence locatedResidential aged care No evidence locatedCommunity No evidence locatedNHMRC Grade of recommendation: C

A nutrition support team(c) may improve outcomes including:Acute care Energy and protein intake128 Level II

Complications and costs129 Level IIl-1Rehabilitation No evidence locatedResidential aged care Weight status130 Level IVCommunity No evidence locatedNHMRC Grade of recommendation: C

Nutrition education provided on malnutrition to health professionals may improve outcomes:Acute care No evidence locatedRehabilitation No evidence locatedResidential aged care No evidence locatedCommunity Global nutritional status131 Level IIl-2NHMRC Grade of recommendation: D

Multi-nutrient oral nutritional supplements (high energy and/or protein) may improve outcomes including:Across settings Body composition,132,133 complications3 and life expectancy3,132,133 Level I

Weight status—evidence of effect112 Level lWeight status—inconclusive3 Level lGlobal nutritional status134 Level llEnergy intake—evidence of effect134 Level llEnergy intake—inconclusive135 Level llHealth care expenditure136 Level III-2

Acute care Weight status;3,112,116 body composition;112,116 complications3,112 andpressure ulcers114

Level I

Life expectancy—evidence of an effect112,132,133 Level lLife expectancy—inconclusive3 Level lEnergy intake;137–141 protein intake;139,141,142 global nutritional status143 and

mood144Level II

Rehabilitation Complications and length of stay145 Level IWeight status;146 body composition146 and physical function147 Level IINutritional biochemistry; self-rated health and well-being148 Level IV

Residential aged care Weight status112 Level IEnergy intake149 Level IV

Community Weight status3,112 Level IEnergy intake;150,151 body composition152 and physical function150,153 Level IICognition and quality of life154 [Aus] Level IV

NHMRC Grade of recommendation: A



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Dietary counselling(d) (with multi-nutrient oral nutritional supplements if deemed necessary) by a dietitian mayimprove outcomes including:

Across settings No evidence locatedAcute care Weight status and physical function155 Level II

Weight status and body composition156 Level IVRehabilitation No evidence locatedResidential aged care No evidence locatedCommunity No evidence locatedNHMRC Grade of recommendation: C

Enteral tube feeding(d) may improve outcomes including:Across settings Complications111 Level IAcute care Weight status157 and length of stay158 Level l

Risk of infection—evidence of effect158,159 Level IRisk of infection—inconclusive3 Level lEnergy intake160 Level IIBody composition;161 nutritional biochemistry;161 and global nutritional

status161,162Level IV

Rehabilitation No evidence locatedResidential aged care No evidence locatedCommunity No evidence locatedNHMRC Grade of recommendation: B

Multi-nutrient oral nutritional supplements or enteral tube feeding in addition to exercise may improve outcomesincluding:

Acute care Weight status and nutritional biochemistry163 Level IIPhysical function164,165 Level IV

Rehabilitation Weight status59 [Aus] Level IIResidential aged care Energy intake and weight status166 Level IICommunity No evidence locatedNHMRC Grade of recommendation: B

Parenteral nutrition may improve outcomes including:Acute care Risk of infection and life expectancy compared to no nutrition

intervention159Level I

Life expectancy compared to EN, particularly delayed EN167 Level INutritional biochemistry168,169 Level IIWeight status170,171 and body composition170 Level IV

Rehabilitation No evidence locatedResidential aged care No evidence locatedCommunity No evidence locatedNHMRC Grade of recommendation: B

Individually prescribed nutritional support using mixed approaches (high energy diets +/- ONS; ETF; PN) mayimprove outcomes including:

Across settings Complications; risk of infection and length of stay111 Level IAcute care Energy intake172 and wound healing173 Level II

Weight status174 and nutritional biochemistry174 Level IVRehabilitation No evidence locatedResidential aged care Weight status; body composition; nutritional biochemistry and physical

function175Level IV

Community No evidence locatedNHMRC Grade of recommendation: C



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RecommendationNutrition interventions can improve outcomes. Consideration should be given to the health care setting, resources,

patient/client goals, requirements and preferences.NHMRC Grade of recommendation: B–C(a) Age, measures of body composition, nutritional biochemistry, global nutritional status (scores generated from two or more indicators ofnutritional status), and other outcomes including physical function, vary across individual studies and readers are referred to study tables todetermine measures used.(b) Studies evaluating food provision methods included strategies such as nutrient density, small portion sizes and improvements to the diningexperience (eg. buffet style meals rather than pre-plated).(c) Nutrition support team interventions ranged from teams including a nurse and a dietitian to teams including nurses, a dietitian, speech andlanguage therapists, caterers and occupational therapists.(d) Further evidence exists for certain patient groups [refer to Evidence Based Guidelines for the Nutritional Management of Patients ReceivingRadiation Therapy].13

NB. Where NICE guidelines are referred to, only findings from meta-analyses are included.3

ETF, Enteral Tube Feed; ONS, High energy and protein multi-nutrient oral supplements; PN, Parenteral Nutrition.

Clinical question

3c: What are appropriate monitoring and outcome measures to demonstrate improved patient, clinical and costoutcomes?

Outcome measuresSuggested frequency of review of measure

being monitored Rationale or clarification

Direct nutrition outcomes:Improving nutrition knowledge Inpatient: Daily initially for patient and

team reducing to twice weekly asknowledge is gained3

Ambulatory: at least fortnightly13

Measure knowledge gained; behaviourchange; adherence to plan.

Improved nutrient intake• Energy Inpatient: Daily initially reducing to

twice weekly when the patient/resident is stable3

Ambulatory: minimum fortnightlydietitian contact13

Monitor using direct observation andquantitative dietary intake methodsespecially of energy and protein.14

Monitor fluid balance.176

Review progress towards nutrient goals;set criteria for commencinginterventions such as high energydiets; ONS; ETF; PN.59 [Aus]

• Protein

• Fluid

Improved nutrition anthropometry:• Body weight Inpatient: daily if concerns about fluid

status, otherwise weekly reducing tomonthly3

Ambulatory: minimum fortnightlyreducing to monthly; biannually aspatient stabilises15

Use calibrated equipment andstandardised techniques andcalculations where required.

Ideally measure MAMC to take intoaccount both body fat andmuscle.175,177

• MAMC Baseline and monthly3

• Tricep skinfold thicknessImproved score on validated global nutrition assessment tool• MNA score134,143

• PG-SGA score178Baseline and monthly Global nutrition assessment tools can

provide pre and post interventioncomparisons so long as there isconsistency in the application of thetool

Clinical and Health Status OutcomesImproved nutritional biochemistry Baseline then weekly3 Many measures of nutritional

biochemistry exist. Caution shouldbe exercised in the interpretations ofbiochemistry particularly in the acutecare setting; consideration should begiven to the cost of testing andburden of testing to the patient.



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Prevention of pressure ulcers114 Patients at risk of developing pressureulcers only: baseline/ admission andthen weekly

Consider a preventative nutritionintervention where there is a risk ofpressure ulcers based on pressureulcer risk tool e.g. Waterlow Pressureulcer tool.114

Improved wound healing Daily Many tools are available; needs to beperformed by an appropriatelyskilled health professional.154,173

Reduced infections and use ofantibiotics

May be a suitable outcome measurefor quality audits of the effectivenessof nutrition interventions

Outcome needs to be monitored at thepopulation level.

Increased peak expiratory flow156 Daily until problem resolves To be performed by appropriate healthprofessional.

Decreased nausea, vomitingand/or diarrhea (from ONSand/or ETF)

Daily until problem resolves Intervene with early feeding wherenecessary. Review tolerance toformula/ feeding regimen to ensureachievement of goals.3,158

Patient-Centered OutcomesImproved quality of life, self rated

health & well beingBaseline and at the appropriate interval

as per tool protocolUse a culturally appropriate tool, e.g.

Medical Outcomes Study 36-itemShort-Form General Health Survey(SF-36) is commonly used.156

Improved mood Baseline and at the appropriate intervalas per tool protocol

Culturally appropriate depressionscales.144,179

Improved physical function Baseline and monthly Many measures of physical functionexist, which may be used to monitornutrition interventions. Tools requiretraining, standardised techniques andcalibrated equipment. Often, themeasures may be undertaken inassociation with an appropriatehealth professional.

—Activities of Daily Living (eg;Katz index)147,155

—Hand-grip strength

Improved cognition Baseline and at the appropriate intervalas per tool protocol

For example, use the results of theMini Mental State Examination(MMSE) tool.154

Improved life expectancy Hospital discharge, quarterly andyearly- audit health informationdatasets

Outcome needs to be monitored at thepopulation level.

Patient satisfaction with nutritionservices provided by dietitians

Yearly- survey of patients180 Outcome needs to be monitored at thepopulation level.

Healthcare utilisation and cost outcomes• Reduced prevalence of

malnutritionYearly-cross-sectional audit of

malnutrition prevalenceOutcome needs to be monitored at

the population level.• Increased referrals of patients at

risk of malnutrition to adietitian

Yearly-audit activity statistics

• Reduced length of stay111 Yearly-audit health informationdatasets

• Reduced readmissions156 Yearly-audit health informationdatasets

• Reduced costs11,136,176 Requires assistance from a HealthEconomist.

RecommendationChoose standardised measures which change in a clinically meaningful way to demonstrate the outcomes of nutrition

interventions.NHMRC Grade of recommendation: N/A

Note: The suggested frequency of review of the measures represents consensus opinion.MAMC, mid arm muscle circumference; MNA, mini nutritional assessment; High energy and protein multi-nutrient oral supplements;PG-SGA, Patient Generated- Subjective Global Assessment; PN, Parenteral Nutrition.



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Nutrition goals; intervention; monitoring practice tips:

3. The NICE Guideline Development Group recommend ‘do not let your patients starve and when you offer themnutrition support, do so by the safest, most simplest, effective route’.3 Consider nutrition support methods availablein your setting, and assess any clinical risks. Ensure nutrition intervention will benefit the patient and ethical and legalissues have been considered as well as clinical outcomes and quality of life.2

3a.i. Nutrition treatment goals and outcomes are based on each patient’s individual nutritional requirements and prefer-ences. The goals address the multifactorial causes of malnutrition identified and prioritised during the assessmentphase and are planned in partnership with the patient and health care team.

3b.i. Nutrition interventions include advocacy for food provision systems which support nutritional adequacy, for example;increased nutrient density (fortification of normal foods),119,163 more frequent meals and fluids,120 improving the eatingenvironment through socialisation,121 help with eating,126,127 and protected mealtimes.181 Ensure staff nutrition edu-cation programmes support these interventions.131

3b.ii. Consider liberalisation of previously prescribed or self imposed diets in older adults.182

3b.iii. Certain disease processes or conditions should mean automatic referral to a dietitian. For example; patients with eatingand swallowing disturbances are often malnourished or at risk of malnutrition if the disturbance continues. Dysphagiais reported to affect 10% of acute patients, 30–60% residents in Residential Aged Care facilities and 10% of the generalpopulation over the age of 50.182 Speech Pathologists are the appropriate health professionals to assess swallowingdifficulties, including aspiration.182 Consultation with a dietitian is also essential to ensure adequate hydration andnutrition can be obtained within the texture and fluid modifications that may be recommended.3,182

3b.iv. Start nutrition intervention prophylactically: for example; in the pre-operative phase provide nutrition interventionsto surgical patients screened as at malnutrition risk and where appropriate continue nutrition support post surgery.113

3b.v. When providing multinutrient oral nutritional supplements, consider the following:• base individual prescription on gap between oral intake and estimated requirements not met through oral intake

alone.149,150

• continuing the nutrition support for an adequate timeframe, since this is correlated with improved weight change.59

• avoid administering high energy and protein multi-nutrient oral supplements (ONS) with meal times.183

• delivering the ONS via the medication round to facilitate adherence.184

• encouraging a supportive environment to facilitate adherence.184

• using dietetic assistants to improve adherence to meal plans and ONS.126

3b.vi. Consider adjunctive therapies which support nutrition status maintenance or improvement. For example; referral toa regular exercise program for malnourished patients to improve function and oral intake.163,165,166

A comprehensive review of the literature on pharmaceutical interventions (orexigenic agents such as megestrol acetateand some anabolic steroids), was beyond the scope of these Guidelines. Please note, however, that these agents mayimprove outcomes relating to energy intake,185 weight status,186–188 body composition,147,187,188 physical function147,187

and quality of life.147,187

3b.vii. It is outside the scope of these Guidelines to address the planning and administration of enteral or parenteral nutrition.Refer to ‘DAA Enteral Feeding Manual for Adults in Health Care Facilities’, ‘DAA Parenteral Nutrition Manual forAdults in Health Care Facilities’, ESPEN; American Society of Parenteral and Enteral Nutrition (ASPEN) and NICEGuidelines.3,189–192

Home enteral and parenteral nutrition guidelines also exist via the NSW Greater Metropolitan Clinical Taskforce(GMCT) Guidelines190 and Australasian Society of Parenteral and Enteral Nutrition (AuSPEN) Guidelines.191

3b.viii. Treatment is timely and incorporates discharge planning and seamless transitions within and across sectors.193 Thetreatment outcomes are specific, measurable, achievable with the allocated resources, realistic to the patients circum-stances and expectations, and the timeframe available.176

3c.i. Audits of malnutrition prevalence and/or dietitian referrals may be useful outcome indicators to evaluate qualityimprovement programmes. For example, O’Flynn et al. 2005, demonstrated a decrease in malnutrition prevalencefollowing the implementation of malnutrition screening; changes in food service delivery and nurse nutritioneducation.118

3c.ii. Root cause analysis of adverse events can be undertaken to improve future nutrition intervention practice. Theoccurrence of events such as refeeding syndrome, aspiration, lack of help with eating, inappropriate restraint ofpatients, inadequate access to appropriate & adequate normal food (example restricted dietary regimes such as clearfluids), should be monitored and reported.



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ACKNOWLEDGEMENT

The Steering Committee would like to acknowledge thefollowing people and organisations for their valuable contri-butions to the development of these guidelines.

Catherine Roe (formerly Hunter New England PopulationHealth NSW), Elizabeth Scott (Orange Base Hospital NSW)and Marian Barré (formerly Prince of Wales Hospital NSW)helped facilitate the workshop ‘Looking beyond the screen-ing tool: establishing best practice processes for malnutritionacross the continuum of care’ at the DAA 24th NationalConference 2006. Acknowledgement is also extended to allparticipants present at this workshop.

Karen Abbey (formerly Queensland Health) and ElizabethScott were founding members of the Steering Committeeformed to drive the guideline development, and assistedwith the development of the clinical questions.

Rachel Sutherland (Hunter New England PopulationHealth NSW) organised funding for the Steering CommitteeResearch Officer to devise and conduct a systematic reviewof the literature.

Stephen Mears, Medical Librarian (John Hunter HospitalNSW), assisted the Research Officer with the literaturesearch.

Fiona Barr (Flinders University), Jennifer Bengtson(Queensland University of Technology), Katrina Campbell(formerly Queensland University of Technology), Karen Fry(John Hunter Hospital NSW) and Jacinda Wilson (Queen-sland University of Technology) helped the committeemembers with sourcing identified articles and dataextraction.

Participants at the DAA 26th National Conference work-shop: ‘Crunch time: Evidence Based Guidelines for theNutritional Management of Malnutrition across the Con-tinuum of Care’ as well as the participants at the DAA 27thNational Conference workshop: ‘Implementing evidencebased guidelines for nutritional management of adult mal-nutrition in your workplace’ for their valuable feedback.

Dietitians Association of Australia funded interstate Steer-ing Committee members to attend a face-to-face workshopin Brisbane in October 2008 to finalise the guidelines.

Finally, appreciation is extended to respective employersfor allowing committee members time to contribute to thedevelopment of these guidelines.

Nutrition & Dietetics 2009; 66 (Suppl. 3): S21


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134 Lauque S, Arnaud-Battandier F, Gillette S, et al. Improvementof weight and fat free mass with oral nutritional supplemen-tation in patients with Alzheimer’s disease at risk of malnutri-tion: a prospective randomized study. J Am Geriatr Soc 2004;52: 1702–7.

135 MacFie J, Woodcock N, Palmer M, Walker A, Townsend S,Mitchell C. Oral dietary supplements in pre- and postoperativesurgical patients: a prospective and randomized clinical trial.Nutrition 2000; 16: 723–8.

136 Arnaud-Battandier F, Malvy D, Jeandel C, et al. Use of oralsupplements in malnourished elderly patients living in thecommunity: a pharmaco-economic study. Clin Nutr 2004; 23:1096–103.

137 Ryan M, Salle A, Favreau A-M, et al. Oral supplements differ-ing in fat and carbohydrate content: effect on the appetite andfood intake of undernourished elderly patients. Clin Nutr2004; 23: 683–9.

138 Potter J, Roberts M, McColl J, Reilly J. Protein energy supple-ments in unwell elderly patients—a randomized controlledtrial. Journal of Parenteral and Enteral Nutrition 2001; 25: 323–29.

139 Vermeeren M, Wouters E, Geraerts-Keeris A, Schols A. Nutri-tional support in patients with chronic obstructive pulmonarydisease during hospitalization for an acute exacerbation;



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a randomized controlled feasibility trial. Clin Nutr 2004; 23:1184–92.

140 Irvine P, Mouzet J, Marteau C, et al. Short-term effect of aprotein load on appetite and food intake in diseased mildlyundernourished elderly people. Clin Nutr 2004; 23: 1146–52.

141 Saluja S, Kaur N, Shrivastava U. Enteral nutrition in surgicalpatients. Surg Today 2002; 32: 672–8.

142 Bourdel-Marchasson I, Barateau M, Rondeau V, et al. A Multi-center trial of the effects of oral nutritional supplementation incritically ill older inpatients. Nutrition 2000; 16: 1–5.

143 Gazzotti C, Arnaud-Battandier F, Parello M, et al. Preventionof malnutrition in older people during and after hospitalisa-tion: results from a randomised controlled clinical trial. AgeAgeing 2003; 32: 321–5.

144 Gariballa S, Forster S. Effects of dietary supplements ondepressive symptoms in older patients: A randomised double-blind placebo-controlled trial. Clin Nutr 2007; 26: 545–51.

145 Avenell A, Handoll H. Nutritional supplementation for hipfracture aftercare in older people. Cochrane Database ofSystematic Reviews. 2006: Art No.: CD001880.

146 Steiner M, Barton R, Singh S, Morgan M. Nutritional enhance-ment of exercise performance in chronic obstructive pulmo-nary disease: a randomised controlled trial. Thorax 2003; 58:745–51.

147 Tidermark J, Ponzer S, Carlsson P, et al. Effects of protein-richsupplementation and nandrolone in lean elderly women withfemoral neck fractures. Clin Nutr 2004; 23: 587–96.

148 Creutzberg E, Wouters E, Mostert R, Weling-Scheepers C,Schols A. Efficacy of nutritional supplementation therapy indepleted patients with chronic obstructive pulmonary disease.Nutrition 2003; 19: 120–7.

149 Lauque S, Arnaud-Battandier F, Mansourian R, et al. Protein-energy oral supplementation in malnourished nursing homeresidents. A controlled trial. Age Ageing 2000; 29: 51–6.

150 Edington J, Barnes R, Bryan F, et al. A prospective randomisedcontrolled trial of nutritional supplementation in malnour-ished elderly in the community: clinical and health economicoutcomes. Clin Nutr 2004; 23: 195–204.

151 Knowles J, Fairbarn M, Wiggs B, Chan-Yan C, Pardy R. Dietarysupplementation and respiratory muscle performance inpatients with COPD. Chest 1988; 93: 977–83.

152 Otte K, Anhlburg P, D’Amore F, Stellfeld M. Nutritional reple-tion in malnourished patients with emphysema. Journal ofParenteral and Enteral Nutrition 1989; 13: 152–6.

153 Price R, Daly F, Pennington C, McMurdo M. Nutritionalsupplementation of very old people at hospital dischargeincreases muscle strength: A randomised controlled trial.Gerontology 2005; 51: 179–85.

154 Collins C, Kershaw J, Brockington S. Effect of nutritionalsupplements on wound healing in home-nursed elderly: Arandomized trial. Nutrition 2005; 21: 147–55.

155 Persson M, Hytter-Landahl A, Brismar K, Cederholm T. Nutri-tional supplementation and dietary advice in geriatric patientsat risk of malnutrition. Clin Nutr 2007; 26: 216–24.

156 Norman K, Kirchner H, Freudenreich M, Ockenga J, Lochs H,Pirlich M. Three month intervention with protein and energyrich supplements improve muscle function and quality of lifein malnourished patients with non-neoplastic gastrointestinaldisease—A randomized controlled trial. Clin Nutr 2008; 27:48–56.

157 Potter J, Langhorne P, Roberts M. Routine protein energysupplementation in adults: systematic review. BMJ 1998; 317:495–501.

158 Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteralfeeding versus ‘nil by mouth’ after gastrointestinal surgery: asystematic review and meta-analysis of controlled trials. BMJ2001; 323: 773–76.

159 Braunschweig C, Levy P, Sheean P, Wang X. Enteral comparedwith parenteral nutrition: a meta-analysis. Am J Clin Nutr2001; 74: 534–42.

160 Sullivan D, Nelson C, Klimberg S, Bopp M. Nightly enteralnutrition support of elderly hip fracture patients: a pilot study.J Am Coll Nutr 2004; 23: 683–91.

161 Hebuterne X, Vaillon F, Peroux J-L, Rampal P. Correction ofmalnutrition following gastrectomy with cyclic enteral nutri-tion. Dig Dis Sci 1999; 44: 1875–82.

162 Hebuterne X, Schneider S, Peroux J-L, Rampal P. Effects ofrefeeding by cyclic enteral nutrition on body composition:comparative study of elderly and younger patients. Clin Nutr1997; 16: 283–9.

163 Bermon S, Hebuterne X, Peroux J-L, Marconnet P, Rampal P.Correction of protein-energy malnutrition in older adults:effects of a short-term aerobic training program. Clin Nutr1997; 16: 291–8.

164 Bourdel-Marchasson I, Joseph P-A, Dehail P, et al. Functionaland metabolic early changes in calf muscle occurring duringnutritional repletion in malnourished elderly patients. Am JClin Nutr 2001; 73: 832–8.

165 Dehail P, Joseph P-A, Faux P, et al. Early changes in isokineticlower limb muscle strength in recovering geriatric subjects onthe basis of nutritional status. Journal of Nutrition, Health &Aging 2005; 9: 356–63.

166 Fiatarone M, O’Neill E, Ryan N, et al. Exercise training andnutritional supplementation for physical frailty in very elderlypeople. N Engl J Med 1994; 330: 1769–75.

167 Simpson F, Doig GS. Parenteral vs enteral nutrition inthe critically ill patient: a meta-analysis of trials using theintention to treat principle. Intensive Care Med 2005; 31:12–23.

168 Hu S, Fontaine F, Kelly B, Bradford D. Nutritional depletionin staged spinal recontructive surgery: the effect of totalparenteral nutrition. Spine 1998; 23: 1401–5.

169 Lapp M, Bridwell K, Lenke L, Baldus C, Blanke K, Iffrig T.Prospective randomization of parenteral hyperalimentation forlong fusions with spinal deformity: it effect on complicationand recovery from postoperative malnutrition. Spine 2001; 26:809–17.

170 Carbonnel F, Messing B, Rimbert A, Rongier M, Koziet J,Darmaun D. Energy and protein metabolism during recoveryfrom malnutrition due to nonneoplastic gastrointestinaldisease. Am J Clin Nutr 1997; 65: 1517–23.

171 Georgiannos S, Renaut A, Goode A. Short-term restorativenutrition in malnourished patients: pro’s and con’s of intrave-nous and enteral alimentation using compositionally matchednutrients. Int Surg 1997; 82: 301–6.

172 Eneroth M, Olsson U-B, Thorngren K-G. Insufficient fluid andenergy intake in hospitalised patients with hip fracture. Aprospective randomised study of 80 patients. Clin Nutr 2005;24: 297–303.

173 Eneroth M, Apelqvist J, Larsson J, Persson B. Improved woundhealing in transtibial amputees receiving supplementary nutri-tion. Int Orthop 1997; 21: 104–8.

174 Fuenzalida C, Petty T, Jones M, et al. The immune response toshort-term nutritional intervention in advanced chronicobstructive pulmonary disease. Am Rev Respir Dis 1990; 42:49–56.



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175 Christensson L, Ek A-C, Unosson M. Individually adjustedmeals for older people with protein-energy malnutrition: asingle case study. J Clin Nurs 2001; 10: 491–502.

176 Russell CA. The impact of malnutrition on healthcare costsand the economic considerations for the use of oral nutritionalsupplements. Clinical Nutrition Supplments 2007; 2: 25–32.

177 Beattie A, Prach A, Baxter J, Pennington C. A randomisedcontrolled trial evaluating the use of enteral nutritional supple-ments postoperatively in malnourished surgical patients. Gut2000; 46: 813–18.

178 Oncology Nutrition Dietetic Practice group. The clinical guideto oncology nutrition, p48–50 second edn. Elliot L, Molseed LL,Davis McCallum P (eds). Chicago: American Dietetic Associa-tion, 2006.

179 Stanga Z, Field J, Iff S, Stucki A, Lobo D, Allison S. The effectof nutritional management on the mood of malnourishedpatients. Clin Nutr 2007; 26: 379–82.

180 Vivanti A, Ash S, Hulcombe J. Validation of a satisfactionsurvey for rural and urban outpatient dietetic services. J HumNutr Diet 2007; 20: 41–9.

181 National Patient Safety Agency. National Patient Safety AgencyProtected Mealtimes Review findings and recommendationsreport http://www.npsa.nhs.uk/EasysiteWeb/getresource.axd?AssetID=2654&type=full&servicetype=Attachment.

182 Hudson HM, Daubert CR, Mills RH. The interdependency ofprotein energy malnutrition, aging and dyspagia. Dysphagia2000; 15: 31–8.

183 Wilson MM, Purushothaman R, Morley JE. Effect of liquiddietary supplements on energy intake in the elderly. Am J ClinNutr 2002; 75: 944–7.

184 Roberts M, Potter J, McColl J, Reilly J. Can prescription ofsip-feed supplements increase energy intake in hospitalisedolder people with medical problems? Br J Nutr 2003; 90:425–9.

185 Simmons S, Walker K, Osterweil D. The effect of megestrolacetate on oral food and fluid intake in nursing home resi-dents: a pilot study. J Am Med Dir Assoc 2005; 6: S5–11.

186 Weisberg J, Wanger J, Olson J, et al. Megestrol Acetate stimu-lates weight gain and ventilation in underweight COPDpatients. Chest 2002; 121: 1070–8.

187 Chu L-W, Lam K, Tam S, et al. A randomized controlled trialof low-dose recombinant human growth hormone in the treat-ment of malnourished elderly medical patients. The Journal ofClinical Endocrinology & Metabolism 2001; 86: 1913–20.

188 Ferreira I, Verreschi I, Nery L, et al. The influence of 6 monthsor oral anabolic steroids on body mass and respiratory musclesin undernourished COPD patients. Chest 1998; 114: 19–28.

189 Volkert D, Berner Y, Berry E, et al. ESPEN Guidelines onEnteral Nutrition: Geriatrics. Clin Nutr 2006; 25: 330–60.

190 Greater Metropolitan Clinical Taskforce. Guidelines forHome Enteral Nutrition (HEN) Services. 2007; http://

www.health.nsw.gov.au/resources/gmct/hen/hen_guidelines_2007_05_28_pdf.asp.

191 Australasian Society of Parenteral and Enteral Nutrition. Clini-cal Practice Guidelines Home Enteral Nutrition in Australia.2006; http://www.auspen.org.au/upload/HEN-Guidelines.doc.

192 Dietitians Association of Australia Nutrition Support InterestGroup (NSW Chapter). Enteral Feeding Manual for Adultsin Health Care Facilities 2007; http://www.daa.asn.au/index.asp?pageID=2145845151. Accessed 5 March 2008.

193 The Australian Council of Healthcare Standards. The ACHSEQuIP 4 Guide: Part 1—Accreditation, standards, guidelines. Stan-dard 1: Clinical. Australian Council of Healthcare Standards,2006.

194 Banks M. Economic analysis of malnutrition and pressureulcers in Qld public hospitals and residential aged care facili-ties. School of Public Health Brisbane: Queensland University ofTechnology, 2008.

195 Stratton R, Longmore D, Elia M. Concurrent validity of a newlydeveloped malnutrition universal screening tool (MUST). ClinNutr 2003; 22: S10.

196 King CL, Elia M, Stroud MA, Stratton R. The predictive validityof the malnutrition screening tool (‘MUST’) with regard tomorality and length of stay in elderly patients. Clin Nutr 2003;22: S4.

197 Kondrup J, Rasmussen HH, Hamberg O, Stanga Z. NutritionalRisk Screening (NRS 2002): a new method based on an analy-sis of controlled clinical trials. Clin Nutr 2003; 22: 321–36.

198 Cooper BA, Bartlett LH, Aslani A, Allen BJ, Ibels LS, PollockCA. Validity of Subjective Global Assessment as a nutritionalmarker in end-stage renal disease. Am J Kidney Dis 2001; 40:126–32.

199 Thoresen L, Fjeldstad I, Krogstad K, Kaasa S, Falkmer U.Nutritional status of patients with advanced cancer: the valueof using the Subjective Global Assessment of nutritional statusas a screening tool. Palliat Med 2002; 16: 33–42.

200 Ottery F. Patient-generated subject global assessment. In:McCallum P, Polisena C (eds). The clinical guide to oncologynutrition. Chicago: American Dietetic Association, 2005.

201 Bauer J, Capra S, Ferguson M. Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutri-tion assessment tool in patients with cancer. Eur J Clin Nutr2002; 56: 779–85.

202 Desbrow B, Bauer J, Blum C, Kandasamy A, McDonald A,Montgomery K. Assessment of nutritional status in hemodi-alysis patients using patient-generated subjective global assess-ment. J Ren Nutr 2005; 15: 211–16.

203 Guigoz Y, Vellas B, Garry PJ. Mini nutritional assessment: Apractical assessment tool for grading the nutritional state ofelderly patients. Facts, Res Gerontol. 1994; 4: 15–59.



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APPENDIX 1: SEARCH STRATEGY

The following tables outline the search terms used for the search of the Medline database using the OVID search engine. Searchterms were then modified for the other databases searched, Embase and CINAHL.

Question 1. Criteria for referral forscreening and referral systems:

What is the best method for identification of adults withmalnutrition or at risk of malnutrition for improved patient,clinical and cost outcomes?

# Search history—Medline

1 exp *Malnutrition/ or malnutrition.mp2 undernutrition.mp3 risk adj2 malnutrition4 1 or 2 or 35 *Risk Assessment/ or *Risk/ or *Risk Factors/6 5 and (malnutrition.ti,ab.)7 4 or 68 *Mass Screening/or *Multiphasic screening9 Malnutrition screening tool.mp

10 Mini Nutrition$ assessment11 Malnutrition Universal Screening Tool12 Nutrition$ risk screen$13 *“Referral and Consultation”14 identif$.tw.15 8 or 9 or 10 or 11 or 12 or 13 or 1416 15 and 717 Limit 13 to (“all adult (19 plus years)” and humans

and English)18 17 not (editorial or tutorial or news or letter or

comment).pt.

Search of MEDLINE, EMBASE and CINAHL databasesfrom inception until August 2006 returned 1627 titles orabstracts.

Question 2. Nutrition assessment andnutrition diagnosis:

Which specific measures best reflect nutritional status orchange in nutritional status in adults with malnutrition or atrisk of malnutrition, for the diagnosis of malnutrition, can bealtered by nutritional intervention and are associated withimproved patient, clinical and cost outcomes?

# Search history—Medline

1 exp *Malnutrition/ or malnutrition.mp2 undernutrition.mp3 risk adj2 malnutrition4 1 or 2 or 35 nutritional status.mp or exp *Nutritional Status6 measure.mp or exp *(Weights and Measures)7 5 and 68 Nutrition assessment. mp or exp *Nutrition

Assessment9 7 or 8

10 9 and 411 malnutrition adj3 diagnosis.mp.12 Malnutrition/di,pc13 10 or 11 or 1214 Subjective Global Assessment15 Full Nutrition$ Assessment16 Mini Nutrition$ Assessment17 Nutrition Risk18 14 or 15 or 16 or 1719 13 or 1820 Limit 19 to (human and English language and “all

adult (19 plus years)”)21 20 not (editorial or news or tutorial or letter or

comment).pt.

Search of MEDLINE, EMBASE and CINAHL databasesfrom inception until August 2006 returned 2025 titles orabstracts.



S28

Question 3. Nutrition intervention (includes goals), nutrition monitoringand evaluation:

(a) What are the nutrition goals for adults with malnutrition or at risk of malnutrition for improved patient, clinical and costoutcomes?

(b) In adults with malnutrition or at risk of malnutrition, what are the appropriate nutrition interventions, to optimisenutritional status for improved patient, clinical and cost outcomes?

(c) In adults with malnutrition or at risk of malnutrition, how will nutrition interventions be monitored for improved patient,clinical and cost outcomes?

# Search history

1 *Malnutrition/nu, dh, dt, pc, rh, th [Nursing, Diet Therapy, Drug Therapy, Prevention & Control, Rehabilitation,Therapy]

2 Exp *Protein-Energy Malnutrition/nu, dh, dt, pc, rh, th [Nursing, Diet Therapy, Drug Therapy, Prevention &Control, Rehabilitation, Therapy]

3 1 or 24 3 and exp adult/5 Limit 4 to (humans and english language)6 *Nutrition Disorders/ nu, dh, dt, pc, rh, th [Nursing, Diet Therapy, Drug Therapy, Prevention & Control,

Rehabilitation, Therapy]7 6 and (malnutrition or malnourish$ or undernourish$).tw.8 7 and exp adult/9 Limit 8 to (humans and English language)

10 5 or 9Exclusions then added to this search included:

1a Exp ascorbic acid deficiency/ or exp vitamin a deficiency/ or exp vitamin b deficiency/ or exp vitamin ddeficiency/ or exp vitamin e deficiency/ or exp vitamin k deficiency/

2a Magnesium deficiency/ or potassium deficiency/3a Exp liver diseases or cystic fibrosis/4a Celiac disease5a Exp Eating Disorders/6a Exp Kidney Diseases7a Renal replacement therapy/ or exp renal dialysis/8a Or/1-79a Exp *ascorbic acid deficiency/ or exp *vitamin a deficiency/ or exp *vitamin b deficiency/ or exp *vitamin d

deficiency/ or exp *vitamin e deficiency/ or exp vitamin k deficiency/ or (magnesium deficiency/ or *potassiumdeficiency/) or exp *Eating Disorders/ or exp *Kidney Diseases/ or (*renal replacement therapy/ or exp *renaldialysis)10 NOT 8a

Search of MEDLINE, EMBASE and CINAHL databases from 1996 until August 2006 returned 335 titles or abstracts.The Cochrane Database of Systematic Reviews was searched using the term malnutrition to identify all relevant Cochranereviews––three identified.



S29

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Table 5 NHMRC—Assessing the body of evidence form

Key question: (circle appropriate grade for each component) Evidence table ref:

1. Volume of evidence (quantity, level, methodological quality and relevance to patients of the body of evidence for thisquestion, based on critical appraisal of each individual study according to Minimum Requirements)

A Excellent (several level I or II studies with low risk ofbias)

B Good (one or two level II studies with low risk of biasor SR/multiple level III studies with low risk of bias)

C Satisfactory (level III studies with low risk of bias orlevel I or II studies with moderate risk of bias)

D Poor (level IV studies or level I to III studies with highrisk of bias)

2. Consistency (the degree of consistency demonstrated by the available evidence. Where there are conflicting resultsindicate how the group formed a judgement as to the overall direction of the evidence)

A Excellent (all studies consistent)B Good (most studies consistent and inconsistency can

be explained)C Satisfactory (some inconsistency, reflecting genuine

uncertainty around question)D Poor (evidence is inconsistent)

3. Clinical impact (the potential impact of recommendation, i.e. size of patient population, relevance of outcomes to thequestion, balance of risks and benefits, relative benefit over other management options, resource and organisationalimplications)

A Excellent (very large clinical impact)B Good (substantial clinical impact)C Satisfactory (moderate clinical impact)D Poor (slight or restricted clinical impact)

4. Generalisability (how reasonable is it to generalise from the results of the studies used as evidence to the targetpopulation for this guideline?)

A Excellent (directly generalisable to target population)B Good (directly generalisable to target population with

some caveats)C Satisfactory (not directly generalisable to the target

population but could be sensibly applied)D Poor (not directly generalisable to target population

and hard to judge whether it is sensible to apply)5. Applicability (the extent to which the body of evidence is directly applicable to Australian healthcare context)

A Excellent (directly applicable to Australian healthcarecontext)

B Good (applicable to Australian healthcare context withfew caveats)

C Satisfactory (probably applicable to Australianhealthcare context with some caveats)

D Poor (not applicable to Australian healthcare context)



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,fr

iend

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etit

ians

in22

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(96%

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ses,

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itiv

ity

=93

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ecifi

city

=93

%

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enst

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0171

USA

(MN

A-S

F)

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erly

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ent

inta

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tw

eigh

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logi

cal

stre

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acut

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ms

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3fo

rea

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eter

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ed

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ory

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up,

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67

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(MU

ST)

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unit

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ss(%

)A

cute

dise

ase

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ctsc

ore

Scor

esof

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for

each

para

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sed

oncu

t-of

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lues

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eter

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effe

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ium

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and

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conc

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ntva

lidit

yw

ith

othe

rsc

reen

ing

tool

s(M

STan

dN

RS)

195

Pred

icts

risk

ofm

orta

lity

and

incr

ease

dle

ngth

ofst

ayan

ddi

scha

rge

dest

inat

ion

inac

ute

pati

ents

196

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drup

etal

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0319

7

Den

mar

k(N

RS

2002

)

Acu

tead

ult

Rec

ent

wei

ght

loss

(%)

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ent

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inta

ke(%

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ISe

veri

tyof

dise

ase

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erly

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es0–

3fo

rea

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cut-

off

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esan

dpr

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ined

seve

rity

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seas

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tal

scor

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3:st

art

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itio

nal

supp

ort

At

adm

issi

onan

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rly

duri

ngad

mis

sion

Med

ical

and

nurs

ing

staf

f

Goo

dag

reem

ent

betw

een

anu

rse,

diet

itia

nan

dph

ysic

ian,

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pa=

0.67

Ret

rosp

ecti

vean

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isof

128

RC

Tsof

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itio

nsu

ppor

t.Pa

tien

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lfilli

ngth

eri

skcr

iter

iaha

da

high

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elih

ood

ofa

posi

tive

outc

ome

from

nutr

itio

nsu

ppor

tPr

ospe

ctiv

est

udy

that

show

eda

decr

ease

dle

ngth

ofst

ayam

ong

pati

ent

sele

cted

atri

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the

scre

enin

gto

ol,

prov

ided

nutr

itio

nsu

ppor

t



S32

Table 7 Summary of the most commonly used nutrition assessment tools. Table adapted from Banks 2008194

Name Author, yearSetting and patient

population Nutrition assessment parameters Rationale/ Clarification

SGASubjective GlobalAssessment91

Setting:Acute91,198,199

Rehab104

Community107

Residential aged carePatient group:

Surgery91

Geriatric48,95,104,107

Oncology199

Renal198

Includes medical history (weight,intake, GI symptoms, functionalcapacity) and physicalexamination

Categorises patients as:SGA A (well nourished)SGA B (mild–moderate

malnutrition) orSGA C (severe malnutrition)

Requires trainingEasy to administerGood intra- and interrater

reliability

PG-SGAPatent GeneratedSubjective GlobalAssessment200

Setting:Acute103,201,202

Patient group:Oncology201

Renal202

Stroke103

Includes medical history (weight,intake, symptoms, functionalcapacity, metabolic demand) andphysical examinationCategorises patients into SGAcategories (A, B or C) as well asproviding a numerical score fortriaging

Numerical score assists inmonitoring improvementsin nutritional status

Easy to administerScoring can be confusing but

this can be addressedthrough training

Patients can complete the firsthalf of the tool

MNAMini-NutritionalAssessment203

Setting:AcuteCommunityRehabLong-term care

Patient group:Geriatric203

Includes:Screening:

6 questionsAssessment:

18 questionsIncludes diet history, anthropometry,

medical and functional statusAssessed based on numerical score

as:no nutritional riskat risk of malnutrition ormalnourished

LengthyLow specificity for screening

section of toolCan be difficult to obtain

anthropometric data in thispatient group

MNA website: http://www.mna-elderly.com

MNA CD (available throughNestle)



S33

APPENDIX 4: TABULAR LISTSOF DISEASES (ICD-10-AMSIXTH EDITION)

Malnutrition (E40–E46)

Note

The degree of malnutrition is usually measured in terms ofweight, expressed in standard deviations from the mean ofthe relevant reference population.

In children, when one or more previous measurements areavailable, lack of weight gain or evidence of weight loss isusually indicative of malnutrition. When only one measure-ment is available, the diagnosis is based on probabilities andis not definitive without other clinical or laboratory tests. Inthe exceptional circumstances that no measurement of weightis available, reliance should be placed on clinical evidence.

In adults, malnutrition includes weight loss of at least 5%,with evidence of suboptimal intake resulting in subcutane-ous fat loss and/or muscle wasting.

If an observed weight is below the mean value of thereference population, there is a high probability of severemalnutrition if there is an observed value situated three ormore standard deviations below the mean value of the ref-erence population; a high probability of moderate malnutri-tion for an observed value located between two and less thanthree standard deviations below this mean; and a high prob-ability of mild malnutrition for an observed value locatedbetween one and less than two standard deviations belowthis mean.

Excludes

Intestinal malabsorption (K90.-)Nutritional anaemias (D50–D53)Sequelae of protein-energy malnutrition (E64.0)Starvation (T73.0)

E40 Kwashiorkor

Severe malnutrition with nutritional oedema with dyspig-mentation of skin and hair

Excludes: marasmic kwashiorkor (E42)

E41 Nutritional marasmus

Severe malnutrition with marasmusExcludes: marasmic kwashiorkor (E42)

E42 Marasmic kwashiorkor

Severe protein-energy malnutrition (as in E43):• Intermediate form• With signs of both kwashiorkor and marasmus

E43 Unspecified severe protein-energy malnutrition

In children, severe loss of weight (wasting) or lack of weightgain leading to an observed weight that is at least three

standard deviations below the mean value for the referencepopulation (or a similar loss expressed through other statis-tical approaches). When only one measurement is available,there is a high probability of severe wasting when theobserved weight is three or more standard deviations belowthe mean of the reference population.

In adults, BMI < 18.5 kg/m2 or unintentional loss ofweight (�10%) with evidence of suboptimal intake resultingin severe loss of subcutaneous fat and/or severe musclewasting.

Starvation oedema

E44 Protein-energy malnutrition of moderate andmild degree

E44.0 Moderate protein-energy malnutrition

In children, weight loss or lack of weight gain leading to anobserved weight that is two or more but less than threestandard deviations below the mean value for the referencepopulation (or a similar loss expressed through other statis-tical approaches). When only one measurement is available,there is a high probability of moderate protein-energy mal-nutrition when the observed weight is two or more but lessthan three standard deviations below the mean of the refer-ence population.

In adults, BMI < 18.5 kg/m2 or unintentional loss ofweight (5–9%) with evidence of suboptimal intake resultingin moderate loss of subcutaneous fat and/or moderatemuscle wasting.

E44.1 Mild protein-energy malnutrition

In children, weight loss or lack of weight gain leading to anobserved weight that is one or more but less than twostandard deviations below the mean value for the referencepopulation (or a similar loss expressed through other statis-tical approaches). When only one measurement is available,there is a high probability of mild protein-energy malnutri-tion when the observed weight is one or more but less thantwo standard deviations below the mean of the referencepopulation.

In adults, BMI < 18.5 kg/m2 or unintentional loss ofweight (5–9%) with evidence of suboptimal intake resultingin mild loss of subcutaneous fat and/or mild muscle wasting.

E45 Retarded development followingprotein-energy malnutrition

Nutritional:• Short stature• StuntingPhysical retardation due to malnutrition.



S34

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