Effectiveness of Nutritional Intervention Led by Clinical Dietitian in Patients at Risk of Malnutrition at the Primary Healthcare Level in Slovenia - Evaluation Study
, , , , oraz | 20 mar 2024
Article Category: Original scientific article
Data publikacji: 20 mar 2024
Zakres stron: 81 - 88
Otrzymano: 18 wrz 2023
Przyjęty: 05 lut 2024
DOI: https://doi.org/10.2478/sjph-2024-0012
Słowa kluczowe
© 2024 Denis Mlakar-Mastnak et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.
It is now widely recognized that patient malnutrition is one of the most serious problems at all levels of healthcare (1,2,3,4). Malnutrition results from inadequate nutrient intake or absorption, leading to unfavourable alterations in body composition, cell mass, decreased physical and mental function, and poor clinical outcomes due to disease (5). Despite the scientific evidence and guidelines, there is a lack of practical implementation of knowledge and as a result, malnutrition often goes unrecognized and untreated (6). Failure to treat malnutrition has negative consequences for patient health and quality of life, as well as negative financial implications for the healthcare system (7,8,9,10,11,12).
In 2019, Klemenc-Ketis et al. (13) provided the only data available in Slovenia on the prevalence of nutritional risk at the primary healthcare level. Their community-based cross-sectional observational study included a population of 1,641 individuals who did not regularly attend family practice. The study revealed that 13.2% of these patients were identified as being at risk of malnutrition, using the Malnutrition Universal Screening Toll (MUST).
Similar to most European countries, Slovenia lacks the integration of nutritional support for patients at risk of malnutrition and nutritional therapy for malnourished patients into the standard medical treatment of all patients at the primary healthcare level. While professional standards for standardized nutritional care processes do exist, their implementation in clinical practice is still pending (14). The Slovenian Association for Clinical Nutrition, in partnership with the Slovenian National Institute of Public Health and Ministry of Health, has developed a comprehensive clinical pathway for integrated nutritional care across all levels of the healthcare system in Slovenia. However, the pathway is yet to be officially published and adopted nationwide.
Clinical dietitians play a crucial role in providing nutritional support in the primary healthcare setting for patients with chronic diseases who are at risk of malnutrition (15). As part of patients’ care, clinical dietitians identify and assess their specific nutritional needs, develop an individualized nutritional plan and provide nutritional counselling. They conduct a comprehensive nutritional assessment of patients’ dietary habits, nutrient intake, medical conditions and individual needs. Based on the assessment, they develop a personalized nutrition plan, considering patients’ nutrient requirements, food preferences and special dietary restrictions. Dietitians may recommend dietary modifications, such as increasing energy and protein intake, to address patients’ nutritional needs and support their optimal health (15, 16).
Strong scientific evidence for the health-related and financial benefits of nutritional therapy exists (17,18,19,20). The implementation of nutritional strategies, such as optimising protein and energy intake in individuals prone to disease-related malnutrition, has the potential to enhance both the nutritional intake and overall nutritional well-being of patients. This can in turn mitigate adverse outcomes for patients and society. However, there is a lack of studies that have examined the effect of nutritional interventions delivered by clinical dietitians at the primary healthcare level in patients with chronic diseases who are at risk of malnutrition or have malnutrition (17).
The objective of this study was to assess the effectiveness of personalized nutritional interventions, administered by a clinical dietitian, in managing nutritional risks among patients with chronic diseases. These interventions were implemented within the framework of the proposed clinical nutritional pathway in two primary health centres in Slovenia. Additionally, the study underscores the importance of regulating nutritional care for such patient groups at the primary healthcare level in Slovenia.
This was a longitudinal evaluation study, utilising a single group pre- and post-test design. We monitored a cohort of patients at nutritional risk of malnutrition at two distinct points: prior to the nutritional intervention and six months after.
The research was conducted across two primary health centres in Slovenia: a sizable centre in Žalec and medium-sized centre in Celje. The study spanned from May 2020 to November 2022 and was approved by the Commission for Medical Ethics of the Slovenian Ministry of Health (number 0120-472/2020/8).
Participants were included in the sample using non-probability (convenience) sampling. The sample consisted of individuals who, throughout the observed period, were identified as being at nutritional risk and received treatment either from a general practitioner (GP) in a primary care physician’s office or from a community nurse providing care at the patients’ homes. Nutritional risk screening was performed by the GP or a community nurse. Adult patients (>18 years) of both sexes at nutritional risk who agreed to participate in the study and met all inclusion criteria were included in the sample.
The study did not include patients whose body mass and muscle strength could not be measured, dying patients, patients with a proven eating disorder, tube-fed patients and patients with a pacemaker. The number of patients included in the nutritional screening was 185. The number of patients at nutritional risk who met all inclusion criteria was 152, and a total of 94 participants completed the 6-month examination. The reasons for dropout are described in Figure 1.
Figure 1.
Participants in the nutrition intervention and the reasons for exclusion or dropout from the study.
The nutrition care process considered all the steps defined in the proposed clinical nutrition pathway (Figure 2). Nutritional risk screening was performed using the established and validated screening tool MUST, which includes three criteria to wdetermine the overall risk of malnutrition: BMI, unintentional weight loss and impact of acute illness. The score obtained for each measure is used to assess the patient’s overall level of nutritional risk. A MUST score of 0 indicates a low risk of malnutrition, a MUST score of 1 indicates a moderate risk, and a MUST score of 2 or more indicates a high risk of malnutrition (21,22,23,24). Due to limitations of the MUST tool, we included additional criteria in nutritional screening when the MUST score was assessed as 0. These were age ≥70 years and BMI <22 kg/m2 with the presence of at least one chronic disease, or the patient had at least one chronic disease and a lower food intake in the last five days (25).
Figure 2.
Proposed clinical nutrition pathway.
Clinically relevant patient characteristics, which were measured as baseline data at the first visit and after six months, included nutritional risk score assessed with the MUST tool, a patient’s nutritional status determined with anthropometric measures of BW, Body Mass Index (BMI) and body composition measures of Fat-Free Mass (FFM) and Fat-Free Mass Index (FFMI). Body composition was assessed with bioelectrical impedance analysis (BIA) using Bodystat Quadscan 4000. Muscle function was evaluated with phase angle (PA), measured with BIA, and hand grip strength, measured with a Baseline hydraulic hand dynamometer following the Southampton protocol (29). Nutritional intake was assessed with the patient’s daily energy intake (kcal/d) and daily energy intake per kilogram of total body mass (kcal/kg TM). Protein intake was assessed with the patient’s daily protein intake per kilogram of total mass (P/kg TM). Nutritional intake was assessed using a 24-hour retrospective recall method and a checklist of specific foods and beverages to verify food intake reported by patients and evaluated using the Prodi® 6 Expert programme (
Patients’ nutritional intakes were estimated according to the most recent ESPEN guidelines for patients with various chronic diseases (30,31,32,33,34,35). A daily energy requirement of 30–35 kcal/kg TM and a daily protein intake of 1.2–1.5 g/kg TM was recommended for all patients, except for lower protein intake for patients with chronic renal insufficiency of 0.8 g/kg TM (36).
Data collection, visualization and statistical analyses were performed using R 4.2.1 version. Descriptive statistics were calculated, and all continuous data were expressed as a mean, median and standard deviation of the mean, minimum and maximum values. The categorical data were expressed as frequencies and percentages. The Kolmogorov-Smirnov test was carried out to test the normality of the continuous variables. Differences in measurements of nutritional status, nutritional intake and functional status before and after intervention were tested using the exact Wilcoxon signed-rank test (EWSRT). The significance level was set to 0.05.
The baseline social demographic and clinical characteristics are described in Table 1.
Baseline characteristics of the sample.
| Female | 59 (63%) |
| Male | 35 (37%) |
| Age, y | 68 [15] (20–92) |
| Alone | 21 (22%) |
| Community (family) | 31 (33%) |
| With partner | 42 (45%) |
| Cardiovascular diseases (including CAF) | 37 (39%) |
| Pulmonary diseases | 4 (4%) |
| Diabetes and other endocrine diseases | 12 (13%) |
| Kidney diseases | 4 (4%) |
| Gastrointestinal diseases | 26 (28%) |
| Diseases of the liver and pancreas | 3 (3%) |
| Oncological diagnoses | 29 (31%) |
| Wounds | 2 (2%) |
| Neurological diseases | 6 (6%) |
| Rheumatological diseases | 2 (2%) |
| COVID-19 | 2 (2%) |
| Other | 13 (14%) |
Note: Values are mean [SD] (minimum-maximum) for normally distributed continuous data and n (%) for categorical data Legend: y=years, CAF=Chronical Atrial Fibrillation, COVID-19=Coronavirus Disease 2019
Among 94 patients participating in the study, 55 (59%) had one chronic disease, 33 (35%) had two, and 6 (6%) had three or more diseases. The comorbidity distribution based on the MUST risk groups are described in Table 2.
Comorbidity distribution based on the risk groups (MUST).
| One comorbidity | 9 | 53% | 46 | 60% |
| Two comorbidities | 7 | 41% | 26 | 34% |
| Three or more comorbidities | 1 | 6% | 5 | 6% |
| Total | 17 | 100% | 77 | 100% |
Legend: MUST=Malnutrition Universal Screening Tool; MUST=0 indicates patients at low risk of malnutrition, MUST≥1 indicates patients with moderate or high risk of malnutrition
An overview of how individuals’ risk group categorization changed after 6 months using the MUST tool is presented in Table 3. It indicates the percentage of individuals who remained in the same risk category, improved their nutritional status or shifted to a higher risk category.
Patients with MUST≥1 (77 patients) were included in the analysis of all changes in their nutritional status, nutritional intake, and functional status. The results are presented in Table 4.
In patients with MUST score of 0, we observed a statistically significant change after six months, as their median daily energy intake increased from 1303 kcal/d to 1990 kcal/d (p<0.001), median energy intake per kilogram of total mass increased from 18.5 kcal/kg TM to 28.0 kcal/kg TM (p<0.001), and protein intake also significantly increased from 0.8 g P/kg TM to 1.2 g P/kg TM (p=0.003).
Contingency table showing frequencies and proportions of patients based on the risk groups (MUST) at the beginning and after six months.
| 0 | 16 | 0 | 1 | 17 |
| 94% | 0% | 6% | 100% | |
| 1 | 25 | 4 | 1 | 30 |
| 83% | 13% | 3% | 100% | |
| ≥2 | 27 | 12 | 8 | 47 |
| 57% | 26% | 17% | 100% | |
Legend: MUS=Malnutrition Screening Tool
Comparison of changes in nutritional status, nutritional intake and functional status in a subgroup of patients with MUST≥1 (n=77).
| BM (kg) | 60.9 (56.50) | 60.9 (56.50) | 63.3 (59.0) | 64.0 (60.0) | <0.001 |
| [14.9] | [14.9] | [15.4] | [15.3] | ||
| (39.1, 100.0) | (39.1, 100.0) | (39.5, 102.3) | (40.0, 103.7) | ||
| BMI (kg/m2) | 22.0 (20.7) | 22.0 (20.7) | 22.8 (21.3) | 23.1 (21.9) | <0.001 |
| [4.9] | [4.9] | [4.8] | [4.7] | ||
| (14.5, 41.1) | (14.5, 41.1) | (14.1, 39.0) | (14.3, 39.0) | ||
| FFM (kg) | 41.5 (38.6) | 41.5 (38.6) | 42.7 (39.7) | 42.8 (39.2) | <0.001 |
| [11.4] | [11.4] | [11.8] | [11.7] | ||
| (19.8, 73.0) | (19.8, 73.0) | (20.2, 77.2) | (20.4, 76.1) | ||
| FFMI (kg/m2) | 14.8 (14.5) | 14.8 (14.5) | 15.3 (14.8) | 15.3 (14.8) | <0.001 |
| [3.0] | [3.0] | [3.0] | [3.0] | ||
| (9.2, 22.5) | (9.2, 22.5) | (7.9, 23.8) | (8.1, 23.5) | ||
| Energy (kcal/kg TM) | 20.7 (20.3) | 20.7 (20.3) | 28.1 (28.7) | 30.3 (30.0) | <0.001 |
| [7.6] | [7.6] | [7.7] | [7.1] | ||
| (5.6, 41.0) | (5.6, 41.0) | (3.1, 46.7) | (13.3, 53.3) | ||
| Energy (kcal/d) | 1217 (1121) | 1217 (1121) | 1722 (1744) | 1876 (1945) | <0.001 |
| [415] | [415] | [438] | [377] | ||
| (369, 2339) | (369, 2339) | (155, 3176) | (850, 2749) | ||
| Protein (g/kg TM) | 0.9 (0.9) | 0.9 (0.9) | 1.3 (1.3) | 1.4 (1.4) | <0.001 |
| [0.4] | [0.4] | [0.4] | [0.4] | ||
| (0.1, 2.3) | (0.1, 2.3) | (0.3, 2.6) | (0.5, 2.5) | ||
| PA (°) | 4.7 (4.7) | 4.7 (4.7) | 5.0 (4.9) | 5.0 (4.9) | <0.001 |
| [1.0] | [1.0] | [1.0] | [0.9] | ||
| (2.4, 7.6) | (2.4, 7.6) | (2.5, 8.8) | (2.8, 7.5) | ||
| Grip strength (kg) | 24 (23) | 24 (23) | 26 (24) | 26 (24) | 0.080 |
| [11] | [11] | [12] | [12] | ||
| (1, 62) | (1, 62) | (1, 64) | (1, 64) | ||
Note: Values are mean (median) [SD] (minimum–maximum).
Wilcoxon signed rank test.
Legend: BM=Body Mass, BMI=Body Mass Index, FFM=Fat-Free Mass, FFMI=Fat-Free Mass Index, TM=Total Body Mass, kcal/kg TM=energy intake per kilogram of total body mass, kcal/d=daily energy intake, g/kg TM=daily protein intake per kilogram of total mass, PA=Phase Angle
In this six-month intervention study, we demonstrated the positive outcomes resulting from the nutritional interventions delivered by a clinical dietitian to patients with chronic diseases at risk of malnutrition. These interventions followed the principles of NCPM (26, 27) and were integrated into the proposed nutrition pathway (Figure 1).
In a subgroup of patients with a MUST≥1 (77 patients), the data show significant improvements in patients’ nutritional intake and nutritional status. Additionally, despite the results of grip strength measurements remaining relatively constant after six months, we found that their functional status, measured with the PA, improved significantly (Table 4). The reduction in nutritional risk was statistically significant for patients initially assessed as having moderate or high risk of malnutrition, whereas low-risk patients exhibited consistent results after the six-month period (Table 3). These findings underscore the critical role of clinical nutritional measures in improving patients’ nutritional and functional status and preventing potential deterioration. To our knowledge, this is the first study that confirmed the benefit of dietetic counselling within a primary healthcare system according to systematic clinical nutritional evaluation through a model of the clinical nutritional pathway.
Our findings are also in line with the results of several studies in different clinical settings investigating the impact of nutritional interventions performed by clinical dietitians across various populations of patients with chronic diseases. Notably, the research on individual dietary counselling for cancer patients undergoing oncological treatment revealed a significant reduction in weight loss by the end of the treatment period due to the nutritional intervention (37, 38). The study further demonstrated improved fulfilment of estimated energy and protein requirements during treatment (37), and individuals in the intervention group exhibited a notably enhanced state of nutrition or anabolic status (38).
Incorporating dietitians into the team for continuous care of geriatric patients following hospital discharge has improved patients’ body mass (39, 40), energy and protein intake (39). However, as with our results, there was not always a statistical improvement in patients’ grip strength (39, 40). Munk et al. (41) evaluated the effects of long-term, individualized nutritional interventions in elderly patients with several chronic diseases at hospital discharge. This intervention focused on optimizing protein intake, with a highlighted emphasis on the importance of strength training. Consistent with prior research (37,38,39,40), the patients in their intervention group lost significantly less body mass and experienced a significant increase in energy and protein intake. In addition, an improvement in physical function, as measured by the chair stand, was observed in the intervention group (41).
Our findings demonstrate that personalized nutritional intervention performed by a clinical dietitian contributes positively to enhancing patients’ nutritional intake, nutritional status and phase angle. Importantly, the lack of improvement in hand grip strength highlights the importance of incorporating a strength training programme for this patient cohort.
The recent systematic literature review of 94 separate studies by Baldwin et al. (42) mainly found low-certainty evidence to suggest that dietary advice given with or without ONS may improve nutritional status in adults with disease-related malnutrition or at nutritional risk. While not revealing distinct patterns regarding the optimal timing for nutritional intervention to be effective across the trajectory of patients’ diseases, the review indicates the feasibility of achieving increased energy intake and weight gain through dietary advice, with or without oral nutritional supplements (ONS) (42).
The favourable outcomes of our study indicate that the selected clinical approach, within the proposed nutritional pathway, integrated essential aspects of patient nutritional care (14). This proved effective even in an environment where knowledge and awareness regarding malnutrition-related issues are lacking. The nutritional pathway enabled the implementation of clinical guidelines in clinical practice, better planning, a patient-centred approach and implementation of effective nutritional intervention for each patient included in the study.
The study results also indicate that periodical individual nutritional counselling over six months enabled the patients to have frequent enough contact with the clinical dietitian, thus maintaining their motivation and enabling them to accept responsibility for following the set nutritional goals. It can also be inferred that periodic verification of anthropometric measurements and dietary intake was an opportunity for patients to monitor the progress of their nutritional status. Thus, there was greater engagement with the proposed nutritional therapy.
The sampling type was convenience, the study was not randomized, and the study included only patients at nutrition risk in two health centres in Slovenia during a specific period, so we should not generalize the results. The primary strength of the study is the high compliance with the nutritional intervention in patients who completed the study, and the major weakness is the high dropout rate of the participants during the study (n=35) and patients who died during the study (n=23) (Figure 1). We presume that the most likely reason is that this study was conducted during the sudden onset and widespread of the COVID-19 pandemic’s mandated social distancing and quarantines.
Individually oriented nutrition dietary counselling and evaluation performed by a clinical dietitian had a beneficial effect on the patient’s nutritional and functional status. The improvement of nutritional status protects patient health and enables better treatment of acute and chronic diseases. Our study confirms that clinical nutrition measures are recommended to be integrated into patients’ treatment as a part of precision medicine. Clinical dietitians in primary healthcare settings play a crucial role in the nutritional care of patients with chronic diseases who are at risk of malnutrition. However, clinical dietitians in Slovenia are sparsely available in primary healthcare and are mainly part of health promotion centres that focus on preventive nutrition care for children and adults. Therefore, the results of this research may significantly contribute to understanding the important role of a clinical dietitian in primary care in Slovenia. It also highlights the need for immediate systemic activities: education of clinical dietitians based on international standards, national regulation of their professional profile and their systematization as health workers.