Letter to the Editor: Dietitian Perspectives: Are We Ready for Nutrition Risk Screening in Community and Primary Care?

Dear Editor,

Nutrition or malnutrition risk is identified through nutrition screening with a valid and reliable screening tool (1) and in the primary care setting can be defined as the presence of factors (e.g., unintentional weight change, difficulty chewing and/or swallowing), which can result in inadequate intake or uptake of the nutrients required for optimal health (2). The COVID-19 pandemic has exacerbated nutrition risk and malnutrition in both community and hospital settings by creating barriers to accessing food and healthcare services, and by producing illness-related symptoms that affect appetite and ability to eat (3–5). In a previous letter to the editor (4), Canadian registered dietitians outlined the importance of addressing barriers to providing nutrition care during the pandemic and beyond.

Nutrition screening is an important nutrition care practice because it involves identifying at-risk individuals and preventing the development or worsening of malnutrition (1, 2). Malnutrition seen at hospital admission often starts in the community, and can result in worse health outcomes, longer hospital stays, and more re-admissions (6–9). Nutrition, and more specifically malnutrition screening, is a feasible and acceptable practice to streamline and promote efficiency in nutrition care in the hospital (10). Although consensus-based nutrition care pathways and other resources to facilitate screening in the community and transitions from hospital have been created (11), implementation is generally low (2, 11). Until nutrition screening in the community is improved, malnutrition as a comorbidity at hospital admission will continue to be prevalent.

We conducted an online survey (QualtricsXM in English and French from June 10 and 18, 2021, respectively, to October 13, 2021) of dietitians (N=47; 97.9% Canadian) working in the community (89.4%; n=42) and other (10.6%; n=5) sectors to determine if nutrition screening is being done at hospital discharge and in the community, including the process, challenges, and opportunities. Survey data was analyzed using descriptive statistics and qualitative description with minimal interpretation.

Nutrition screening when transitioning from hospital to community is rare, with only 19.2% (n=9)* of participants indicating that their local hospitals screen at this time. Among participants practicing in the community, 62.2% (n=28) reported not screening discharged patients. For participants who do complete nutrition screening with patients after hospital discharge (26.7%; n=12) and at regular appointments (34.2%; n=14), a variety of tools are used, with no single tool being most common. Those who are deemed at nutrition risk are usually referred to a registered dietitian. Although 84.4% (n=27) of participants indicated that they want to screen for nutrition risk to prevent malnutrition, many factors were cited as barriers to implementing nutrition screening in practice.

Predominant barriers cited by participants were lack of time, inadequate communication between hospital and community practices, and uncertainty regarding referral processes. The shortage of registered dietitians employed in primary care also makes it difficult to accept referrals, even if patients are screened. Of those able to conduct nutrition screening, more guidance and training are required on how to support and encourage nutrition screening processes.

Evidence suggests that nutrition screening at hospital discharge and in the community is feasible (2), yet it continues to occur in the minority of patients. Nutrition screening in primary care and the community must be prioritized so that risk is identified and treated early. Facilitators suggested by participants to promote nutrition screening are: improved communication and connection of electronic medical record systems between hospital and community practices; nutrition screening education and support; dietetic champions; and a valid nutrition screening tool. The Canadian Malnutrition Task Force that spearheaded this survey will continue to develop guidance and resources for implementing nutrition screening to help healthcare and social service providers integrate it as a regular part of their practice.