What do you think of when you hear the word ‘malnutrition’? Many of us associate it with starvation, poverty and unhealthily low body weight – stereotypes that have been reinforced by charity advertisements and mainstream media.
But here’s the truth: malnutrition isn’t limited by body type or wealth or to developing countries.
It can affect literally anyone, including people who might outwardly look healthy and active. In Australia, malnutrition is most common among the elderly, those who don’t eat a balanced diet, and those affected by chronic disease. Older Australians are particularly at risk, with research indicating that up to 40% of hospital patients and up to 50% of aged care residents are malnourished [1, 2].
Think about that for a moment. Statistically, half of Australia’s aged care population are suffering from malnutrition. That might include your parents, your grandparents, or even you yourself.
It’s a frightening concept, and one that many people aren’t aware of. That’s why getting a basic understanding of malnutrition is so important – it’s the type of information that could prevent you or your loved ones suffering serious health complications down the track.
Independence and self-sufficiency – two things we all want to keep as we get older – are both threatened by malnutrition. When we finally make it to retirement, our golden years should belong to our hobbies, our partners and our grandchildren.
No-one wants to spend weeks or even months lying in hospital beds, fatigued and riddled with slow-healing infections, when they should be at home, enjoying life.
So do yourself a favour. Read this article, learn about malnutrition, and learn how to prevent it from happening to your loved ones or patients.
What is malnutrition?
Malnutrition is a bracket term that includes more than just undernutrition (not eating enough relative to energy expenditure). While undernutrition is the most common type of malnutrition, it can also occur if you aren’t consuming a diversified diet or are overconsuming energy-dense foods, which is why overweight or obese people can also be malnourished. This type of malnutrition is called ‘overnutrition’.
What is undernutrition?
Undernutrition (also known as energy undernutrition or protein-energy malnutrition) occurs when your body has too few of the right nutrients. This normally occurs if you can’t eat enough food to offset your energy requirements.
Undernutrition can be caused by many factors, including chronic disease, age, hospitalisation, certain medical conditions, malabsorption, dementia and dysphagia.
What is overnutrition?
Overnutrition is a form of malnutrition that occurs when your body has too many nutrients, leading to the accumulation of body fat, which, in turn, causes other health problems like cardiovascular disease, certain types of cancer and type 2 diabetes . Being overweight or obese is normally a result of overnutrition. Symptoms include :
What are the causes of malnutrition?
Because malnutrition is such a complex issue, it can be caused by a variety of factors. Let’s have a look at some of the most common reasons for malnutrition in Australia.
Inadequate dietary intake
If someone has trouble eating food, they’re more likely to become malnourished. Inadequate dietary intake might occur for lots of different reasons, but some common risks include:
- Increased nutritional requirements due to a disease state, like Parkinson’s disease 
- Loose or ill-fitting dentures
- Difficulty opening food packaging due to arthritis
- Decreased taste and smell (which leads to reduced appetite)
- Difficulty shopping and preparing meals
- Lack of interaction with others at mealtimes
- Loneliness and/or anxiety
- Difficulty eating and drinking
- Nausea, vomiting, constipation and/or diarrhoea
- Reduced or lack of appetite and disinterest in food
- Financial concerns, which lead to skipped meals and low-nutrient food
- Illnesses that cause increased nutrient requirements (like cancer and other autoimmune disorders), increased nutrient loss (enterocutaneous fistulae or burns), poor nutrient absorption or a combination of these factors (ongoing vomiting or diarrhoea) 
Medical conditions, acute or chronic illnesses and medical treatment can affect appetite and food intake, preventing patients from either eating enough or absorbing nutrients properly. These can include mental health conditions like anorexia nervosa and major depression, chronic health conditions like cancer and rheumatoid arthritis, and acute health conditions like infections, burns and injuries .
It’s not always illness or injury that causes hospital-acquired malnutrition, either. Patients may not feel hungry (due to medication or other factors), might have increased energy needs due to surgery, might miss meals due to hospital or might simply dislike hospital food!
Sometimes, even intentionally reduced food intake can result in malnutrition.
Pre- and post-operative fasting can contribute to existing malnutrition risks, which, in turn, can result in greater chances of surgical complications and morbidity  Additionally, some medical conditions, like chronic pain, can be successfully managed through fasting or restricted diets, which sometimes results in protein-energy malnutrition .
If your patient or loved one is preparing to have surgery or following medically recommended fasting, make sure you monitor them for signs of malnutrition.
Older Australians are the most at-risk demographic from malnutrition, as ageing can cause problems like reduced functional capacity, poor dental health, polypharmacy (taking lots of medication), swallowing problems and reduced senses of smell and taste .
Food becomes both harder to eat and less appealing, so it’s easy for older people to skip meals due to fatigue or lack of appetite. Because our appetites decrease and our protein requirements increase as we age, this can create nutritional imbalances very quickly.
Another important consideration is that our bodies naturally absorb certain vitamins less effectively as we age, and certain medications, surgeries and disorders can all accelerate this process .
It’s also important to make the distinction between minor, gradual age-related muscle loss and rapid or severe weight loss, which is probably the result of malnutrition or another serious medical condition. Nutritional frailty is not normal, and results in slower wound healing, increased risk of falls, and higher disability and morbidity .
Oral dysphagia and impaired swallowing
Dysphagia, which refers to difficulty swallowing, can have a big impact on a person’s diet. It’s a condition that can arise for several reasons, including dry mouth (xerostomia) and strokes, and diminishes the ability to eat normally.
People with dysphagia struggle to swallow regular food, and often need thickened fluids, thickened supplements and texture-modified diets to both minimise the risk of choking and achieve adequate nutrition and hydration.
Both untreated and undiagnosed dysphagia has been linked to malnutrition, particularly when it occurs in settings like aged care homes and hospitals .
Malabsorption conditions and syndromes
Malabsorption means a person’s body has trouble absorbing nutrients from food. This means that a person might eat a ‘normal’ amount of food but only absorb a certain percentage of the nutrients, leading to malnutrition .
Cognitive decline and dementia
Individuals suffering from mental decline or dementia are also at particular risk of malnutrition. As a result of their condition, they might :
- Experience loss of appetite
- Forget how to prepare meals for themselves
- Forget how to eat, drink, chew or swallow
- Experience dry mouth, oral discomfort or difficulty swallowing
- Be unable to recognise the food and drink they are given
What are the signs and symptoms of malnutrition?
Malnutrition is a complex condition that affects everyone differently. In this section, we’ll break down exactly what undernutrition, rather than overnutrition, looks like.
Signs of undernutrition
Indications that you or a loved one aren’t eating enough include :
- General loss of appetite
- Losing muscle
- Unexplained or unintentional weight loss
- Fatigue, tiredness, loss of energy, confusion and poor concentration
- Reduced ability to perform normal tasks
- Reduced physical performance, like not being able to walk as far or as fast as usual, difficulty preparing meals or difficulty performing other daily activities.
- Displaying altered mood states, like lethargy, irritability, apathy (a lack of interest and motivation) or depression
- Wounds heal more slowly
- Skin tears more easily
Signs and symptoms of severe undernutrition :
What are the effects of malnutrition?
We’ve covered what the signs and symptoms of malnutrition are, so now it’s time to look at how protein-energy malnutrition can affect our long-term health.
Some of these effects include:
- Reduced wound healing
- Weakened immune systems
- Increased risk of falls and fractures
- Increased chance of pressure sores
- Prolonged hospital admissions
- Higher mortality
These effects are particularly dangerous for elderly individuals, and can lead to a spiral of ill health. Because their bodies aren’t receiving the right nutrients, they are more likely to develop infections or injure themselves. These new traumas, in turn, take much longer to heal than normal, which can lead to longer hospital stays and more severe, longer-lasting pressure sores.
Once in hospital, they’re likely to eat less, which continues the spiral and eventuates in a significantly higher risk of mortality. That’s why prevention is always better than treatment – once the spiral of ill health begins, it’s very difficult to correct, and could have irreversible impacts on your patient or loved one.
Can overweight or obese people suffer from protein-energy malnutrition?
Although it might seem contradictory for an overweight person to be malnourished, it can and does happen to sick or hospitalised individuals. These people might not appear visibly malnourished, but they can still suffer the effects of malnutrition listed above .
Have an overweight loved one at home, in an aged care home or in hospital? It’s important that you use nutrition screening tools to identify whether they might be at risk of malnutrition. Keep reading to find out exactly what the Malnutrition Screening Tool is and how to use it.
How can nutrition screening identify and prevent malnutrition?
Healthy people can prevent malnutrition by following a balanced diet based around whole foods. For elderly individuals and hospitalised patients, prevention is harder. Underlying health conditions can make both demographics susceptible to malnutrition, and can also prevent health professionals from identifying them as malnourished.
Understanding how to identify and prevent malnutrition is, therefore, particularly important if you:
- Have parents or grandparents aged 65 years or older
- Work in a hospital environment
- Work in a residential aged care home
- Work with individuals living with dysphagia, who are also vulnerable to malnutrition
An easy way to identify whether someone is at risk of becoming malnourished is to use the Malnutrition Screening Tool (MST), available here . The MST is a simple, quick and reliable tool designed to help family, friends, nurses, medical professionals, dietitians and administrative staff discover whether a person is at risk of malnutrition.
To use the MST, just ask your patient or loved one two questions:
1. Have you lost weight recently (in the last six months) without trying?
2. Have you been eating poorly recently because of decreased appetite?
Then use both of the below tables to assign them a score:
Question 1 Scores
|Have you lost weight recently without trying?|
|Their answer||Their score|
|Yes, 1-5 kilograms||1|
|Yes, 6-10 kilograms||2|
|Yes, 11-15 kilograms||3|
|Yes, more than 15 kilograms||4|
|Yes, but they’re not sure how much||2|
Question 1 Tips
The emphasis in Question 1 is on ‘without trying’. Diets or intentional weight loss should not be counted.
If they’re unsure, ask about things that might indicate weight loss, like whether clothes and rings are looser or if they’re using a different belt notch.
Question 2 Scores
|Have you been eating poorly recently because of decreased appetite?|
|Their answer||Their score|
Question 2 Tips
The emphasis in Question 2 is on ‘eating poorly’. Eating poorly is due to decreased appetite, but there may also be other reasons, such as chewing/swallowing difficulties.
Clarify by asking them how much less food they’re eating – e.g. half of their normal food intake, one-third of their normal food intake, etc.
Total the Scores
Add the scores from both tables together to get a total score.
- A total score of 0-1 = low risk of malnutrition
- A total score of 2 = moderate risk of malnutrition
- A total score of 3-5 = high risk of malnutrition
If they receive a score of 0-1, that’s great! They’re currently unlikely to be malnourished. Make sure you keep an eye on them by rescreening them monthly – prevention is always better than treatment.
- Put them on a high protein and high energy diet (we’ll talk more about what that looks like in a minute).
- Give them nutritional supplements.
- Refer them to an Accredited Practicing Dietitian.
- Weigh and rescreen them weekly, as small amounts of weekly weight loss can add up over time.
How can malnutrition be treated?
Malnutrition can normally be prevented by identifying risk factors, testing your loved ones or patients using the MST, and modifying their diet accordingly. If you’ve identified a loved one or patient at risk of malnutrition, it’s a good idea to try these nine helpful tips.
The top 9 ways to treat malnutrition
1.Consume a high protein and high energy diet
2.Eat proteins and desserts first
3.Eat small, frequent meals
4.Make meals visually appealing
6.Make meals enjoyable
7.Use nutritional supplements between meals
8.See an Accredited Practicing Dietitian
9.Check weight monthly
1. Consume a high protein high energy (HPHE) diet
When a person is undernourished, you want to make sure they’re eating as many carbs, proteins and fats as possible. A high protein high energy (HPHE) diet is a strategy for increasing the protein and energy content of food without increasing the volume of food. This can be very useful when someone has a small appetite.
Foods with high protein density include:
- Meat, like lamb, beef, chicken
- Seafood, particularly oily fish like salmon and sardines
- Legumes like baked beans, chick peas and lentils
- Dairy, like milk, cheese and yoghurt
- Nuts and seeds
- Food fortification powders like AdVital
- Nutritional supplements like Recover
Good sources of high energy food include:
- Full-cream dairy products
- Bread, cakes and pastries
- Breakfast cereals
- Potato, sweet potato and corn
- Butter, margarine, salad dressing and various oils
- Jam, honey and golden syrup
- Nutritional supplements like AdVital and Recover
You can create meals with high energy by:
- Adding peanut butter to dishes
- Serving fruit with cream, ice cream or custard
- Frying or cooking in oils
- Adding cheese to dishes
- Drinking milk-based drinks (smoothies, flavoured milk, iced coffee) instead of plain tea and coffee
- Fortifying plain tea and coffee
- Adding butter to dishes
- Doubling the protein portion of dishes
2. Eat protein and dessert first
Because proteins (meat/fish) and desserts are high in both protein and energy, it’s a good idea to eat these first, especially if your patient or loved one gets full easily. Vegetables normally aren’t as protein-rich, so they should be consumed last.
3. Eat small, frequent meals
Eat six to eight small meals and snacks throughout the day by aiming to eat every two to three hours. Small, frequent meals can boost your nutrition intake, and can be useful if you feel full quickly or if your appetite has decreased.
Eating smaller meals more often also means a person’s energy intake is more balanced, which helps their body process nutrients more efficiently .
4. Make your meals visually appetising
In some situations, a lack of appetite can contribute to or be symptomatic of malnutrition. If your loved one or patient isn’t enthusiastic about their meals, try putting extra effort into presentation.
Ghrelin, the hormone that regulates hunger, is stimulated by visual cues, so creating delicious, aesthetically appealing meals can actually help promote a better appetite .
This is particularly important for people on texture-modified diets – minced and pureed food doesn’t look particularly yummy! That’s why products like Flavour Creations’ Shape It are so great. Shape It is an instant moulding powder you can add to texture-modified foods to help them look completely natural, without compromising smell, flavour or texture. Shape It is heat-activated, and, once it’s mixed into minced or pureed food, foods can be shaped to resemble their standard and recognisable appearance. It’s that simple!
It’s also important not to overload your loved one or patient’s plate. Meals that look overwhelmingly large can deter a person from even starting to eat. If necessary, try serving meals on bigger plates with more white space – this helps the food itself seem smaller.
5. Eat fortified foods
Fortified or enriched foods are one of the easiest ways to combat malnutrition. ‘Fortified’ or ‘enriched’ means that the food or drink in question has had additional protein, energy, vitamins and minerals added to it . Some foods are fortified pre-packaging, but fresh-cooked meals can also be enriched with nutritional powders. These powders can be mixed into food to boost protein, energy and vitamin levels.
Our favourite? AdVital. AdVital’s neutral-flavoured powder is packed with 15 grams of protein and 27 vitamins and minerals. It’s designed to mix easily into everyday meals like cereal milk, scrambled eggs, pasta, porridge, soup or mashed potato, so you don’t need to worry about glugging down unpleasant-tasting smoothies or swallowing handfuls of tablets.
AdVital’s neutral flavour is one of its most impressive features. Many fortification powders have unpleasant or noticeable tastes, which can affect appetite and meal enjoyment, and are only suitable for adding to certain types of food (like dairy). Neutral-flavoured powder, by comparison, can be mixed into literally any food without changing the flavour, making it a versatile option for fighting malnutrition.
6. Make meals more enjoyable
Because malnutrition can be exacerbated by a lack of enjoyment or interest in food, it’s a great idea to make meals something to look forward to, rather than a chore to struggle through. You can do this by:
- Adding a community aspect to meals. Positioning meals as a time to interact with friends and families is useful for getting older people (particularly those in aged care) to the table.
- Making meal spaces welcoming and comfortable. This might include adjusting temperature controls to a warmer level, making seating more comfortable, adding more light or offering an outdoor eating space. If possible, consider adding a television so people can watch their favourite shows while eating.
- Providing easy-to-use plates and cutlery. Plates and cutlery that are too heavy or awkward can reduce the ability and inclination to eat, particularly in people who are suffering from frailty or muscle weakness.
- Always remembering to tailor your approach to your loved one or patient’s personal preferences. For example, if someone is self-conscious about eating, they might find it discomforting to eat in front of others, so a better idea would be to make their room a comfortable eating space.
7. Use nutritional supplements
Another strategy to fight malnutrition can be to bulk up meals with nutritional supplements.
Nutritional supplements work because they normally have high energy and protein. This means that they contain a comparatively high amount of calories, which is exactly what malnourished people need to recover faster.
Some of them, like Recover by Flavour Creations, are specifically designed to help combat malnutrition in older people and hospital patients. Clocking in at double the protein of other fruit-flavoured oral nutrition supplements, Recover’s small serving size and appealing taste make it perfect for people who are struggling to get enough protein. It can be drunk between meals and is designed for all Australians – it’s dairy-, lactose-, fat- and gluten-free, and is both kosher- and halal-certified.
We recommend using supplements like Recover and AdVital in combination with a variety of other strategies. Try getting your loved one or patient to eat six to eight small meals of high-protein high-energy foods (one of which can be enriched by AdVital), with two to three Recover drinks in between meals.
8. Get a referral to a dietitian
If none of the above tips are working and your patient or loved one has scored 2+ using the MST, it’s time to get a referral for an Accredited Practicing Dietitian. You can make an appointment with a dietitian yourself, but getting a referral from a GP means you might be eligible to have Medicare cover the cost.
You can find accredited practicing dietitians using the Dietitians Australia website.
9. Monthly weight checks
Remember to keep re-screening, weighing and visually assessing your patient or loved one every month. Doing this will help pick up significant weight changes, and will alert you if they’re at risk of becoming malnourished.
The nine tips we’ve talked about are great for treating malnutrition, but the best way to prevent it in the first place is by following a healthy diet that focuses on whole foods.
Wondering exactly what that looks like for older people? Check out the Nutritional Secrets to Ageing Healthily. It’s an article we wrote that covers exactly what foods you should eat as you get older, and even breaks down the science behind which macro and micronutrients are the most important.
To find out whether a patient or a loved one might be malnourished, use the Malnutrition Screening Tool (MST). The MST can detect the risk of malnutrition early, and can prevent it before extensive treatment is required.
If someone you know has scored 2 or higher using the MST, you should follow the tips outlined in this article; in the event that their condition does not improve, you should book an appointment with a professional dietitian.
Medical information on FlavourCreations.com.au is merely information and is not the advice of a medical practitioner. This information is general advice and was accurate at the time of publication. For more information about nutrition and your individual needs, see your GP or an Accredited Practising Dietitian.
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