The Attitudes and Knowledge of Family Physicians Regarding Malnutrition in The Elderly: A Call for Action

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This study aims to evaluate family physicians' knowledge and attitudes towards the diagnosis and treatment of malnutrition in the elderly. Methods Based on a literature review, an online questionnaire was developed, comprised of seven knowledge-related items and eight attitude-related questions regarding malnutrition in elderly populations. We also assessed the feasibility of including two malnutrition screening questions in regular clinic visits for individuals aged ≥ 70 years. Results Surveys were completed by 126 physicians (35% response rate), mean age 47.2 ± 12.6 years; 15.6 ± 12.5 years of practice; 67% females; and 92% board-certified family physicians. Moreover, 77.6% agreed that diagnosing malnutrition is important in patients with decreased appetite. Most respondents demonstrated knowledge of nutritional screening principles (63.5%) and recognized that even obese elderly individuals could be malnourished (83.2%). There was partial agreement (60%) that normal BMI values in the elderly differ from those in younger populations. Almost complete agreement was seen for incorporating two nutritional status questions in medical visits (91%), with physicians expressing willingness to receive training in malnutrition identification and screening tools. Despite challenges such as time constraints and limited knowledge, participants were open to conducting biannual malnutrition risk screening for elderly patients. Conclusion We therefore recommend malnutrition diagnosis based on the Global Leadership Initiative on Malnutrition (GLIM) criteria and utilizing existing medical records, into primary care practices. This could be further enhanced through artificial intelligence, increasing awareness of malnutrition among family physicians. Malnutrition Elderly Family physician GLIM Figures Figure 1 Introduction Malnutrition is a complex condition that has numerous etiologies, that may develop independently or following the interaction between food deprivation and catabolic processes that are linked to disease-related inflammation 1 . In general, it is estimated that 5–26% of older adults are at risk of malnutrition 2 . Older adults, aged 70 years and above, are at even higher risk, due to a range of physiological and social factors, such as frailty, reduced appetite, sensory impairments, poor dentition, swallowing problems, depression, dementia, and even social isolation 3 . Malnutrition could have serious consequences on the individual, such as impaired healing of wounds, reduced immunity 4 , higher risk of falls 5 , impaired functionality 6 , increased mortality risks 7 , and decreased quality of life 8 . The burden of malnutrition on health care is significant, taking a toll on resources such as expenses and manpower 9 . According to the recent Vienna Declaration, nutritional care is an emerging human right, in line with the understanding that nutrition is a fundamental aspect of health and well-being. Moreover, it lies at the intersection of the existing human rights to food and to health, i.e., “the right to be fed” 10 . Family Physicians (FP) working in the community serve as the initial point of contact for patients within the healthcare system, therefore, they are ideally positioned to identify patients with malnutrition and refer them to other health care professionals for further assessment and treatment. Although malnutrition in the elderly is a global concern, a fundamental lack of consensus can be seen regarding the criteria for diagnosing malnutrition in clinical settings. The International Classifications of Diseases (ICD) focuses on identifying nutrient deprivation and deficiency. 1 However, the clinical settings and snapshot of global malnutrition has greatly evolved over time, becoming even more complex and intricate. Indeed, this is expected to be addressed in the next ICD to be issued, to provide the clinical nutrition community with more specific coding regarding malnutrition in adults – one that reflects current malnutrition perceptions and may support clinical decision-making in everyday practice 1 . To adequately and accurately diagnose and document malnutrition in medical records, reliable and valid diagnostic tools are needed 11 . One such tool that encompasses the expertise of several nutritional societies is the Global Leadership Initiative on Malnutrition (GLIM) – a global consensus on core criteria for diagnosing malnutrition in adults in all health care settings 12 . The GLIM diagnostic framework is currently being validated for older populations across a variety of settings and clinical conditions 13 . Yet, a recent review of the current literature on identification and treatment of malnutrition in older adults identifies gaps between research evidence clinical practice 14 . This study aimed at examining such gaps in Israel, by assessing FPs’ knowledge and attitudes toward malnutrition diagnosis and treatment in the elderly, with an emphasis on barriers in the use of this diagnostic tool for identifying elderly patients with malnutrition in Israel. Methods Subjects and Research Design In 2022, an online survey was sent to FPs from the four main health maintenance organizations (HMOs) in Israel. To increase the response rate, the questionnaire was kept as short as possible (5–10 minutes to complete). The electronic questionnaire included seven statements regarding the FPs’ attitudes towards diagnosing and treating malnutrition in the elderly and six statements regarding their knowledge of these topics. For each of the 15 items included in the questionnaire, the respondents were asked to choose their degree of agreement, from the following five options: 1) completely agree; 2) agree; 3) partially agree; 4) disagree; or 5) completely disagree (Appendix 1). Additional questions were included in the survey regarding barriers and willingness to screen for malnutrition; the respondents were also asked to provide demographic data, including gender, age, years of experience as a physician (including specialization in family medicine), number of years of experience as board certified family physicians, region of practice (north south), type of clinic (urban, rural, or both), and whether there is a dietician at their clinic. A total of about 300 physicians were approached to participate in this study, recruited through three channels: ( 1 ) National on-line network of FPs; ( 2 ) e-mail sent to all FP's who work in the southern region of the country; and ( 3 ) during a large conference for FP's. The respondents provided their informed consent prior to completing the questionnaire. The study was approved by the Ethics Committee of. of Ben-Gurion University, Faculty of Health Sciences (06/2022). Questionnaire Development The focus of the questionnaire is nutritional screening, diagnosing and treating malnutrition. A review of the literature was conducted to provide initial direction for creating the survey, with the included items and questions being related to the various topics that emerged from this review. Moreover, an emphasis was placed on two of the most consistent risk factors for malnutrition: involuntary weight loss and decreased appetite; In addition, we asked about Sarcopenia – a nutritional disorder which is frequently overlooked in elderly patients 4,15,16 . Data Analysis Data analysis was conducted using SPSS v. 27.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to depict the respondents’ level of agreement with each of the statements, using the three following categories: ( 1 ) ‘agree’ (a combination of completely agree and agree ); ( 2 ) ‘partially agree’; and ( 3 ) ‘disagree’ (a combination of completely disagree and disagree ). Chi square was calculated to compare responses by gender and years of experience. Results A total of 126 physicians participated in the study (67% females). As seen in Table 1 , their mean age was 47.2 years (SD ± 12.6), Most were board certified family physicians (92%) who had studied medicine in Israel (75%). The mean number of total years of experience as a physician was 15.6 years (SD 12.5) and as a FP 10.2 years (SD 11.3). Table 1 Respondents’ demographic characteristics (N = 126) Characteristic Data Age M(SD) = 47.2 ± 12.6 Females n = 84 (67%) Family physicians n = 112 (92%) Studied medicine in Israel n = 94 (75%) Years of experience as physician M(SD) = 15.6 ± 12.5 Years of experience as Family physicians M(SD) = 10.2 ± 11.3 Insert Table 1 about here As seen in Table 2 , most FP's (92.7%) agreed that diagnosing malnutrition is important. Similarly, most FPs (77.6%) agreed that in elderly patients with decreased appetite, nutritional assessments are necessary. However, only about one-third (35.2%) stated that they have adequate knowledge in the field of nutrition, and less than half (46.4%) stated that nutritional screening should be performed by nurses rather than by physicians. About one-third (35.5%) agreed that involuntary weight loss should be treated with oral nutritional supplement (ONS). Finally, 38.9% of the respondents attributed lack of time and lack of personnel as barriers in screening for malnutrition. Table 2 Attitudes of family physicians towards diagnosing and treating malnutrition in the elderly Fully agree n (%) Partially agree n (%) Disagree n (%) 1 In my opinion, the knowledge I have in the field of nutrition is sufficient to help my elderly patients 33 (26.4) 44 (35.2) 48 (38.4) 2 It's more important to treat obesity than malnutrition 5 (4.0) 11 (8.7) 110 (87.3) 3 It's important to identify malnutrition in elderly patients, to improve their quality of life 117 (92.9) 5 (4.0) 4 (3.2) 4 Screening for malnutrition in the elderly should be performed by nurses, who should refer them to a dietician if needed 58 (46.4) 44 (35.2) 23 (18.4) 5 When patients report a loss of appetite, they should undergo a nutritional assessment 97 (77.6) 20 (16.0) 8 (6.4) 6 When elderly patients report having lost 2–3 kilograms in three months, the physician should recommend that they consume oral nutritional supplements, such as Ensure or Nutren 12 (9.7) 44 (35.5) 68 (54.8) 7 Carrying out nutritional screening of elderly patients in the clinic is not possible, due to lack of time and personnel 49 (38.9) 37 (29.4) 40 (31.7) Table 3 Knowledge of family physicians regarding diagnosing and treating malnutrition in the elderly Fully agree N (%) Partially agree N (%) Disagree N (%) 1 Elderly people who are obese cannot suffer from malnutrition as well 7 (5.6) 14 (11.2) *104 (83.2) 2 When an elderly patient is in a state of sarcopenia (loss of muscle strength and muscle mass), I refer him/her to a dietician 72 * (57.1) 36 (28.6) 18 (14.3) 3 Older patients who are overweight should be encouraged to lose weight 42 (33.3) 40 (31.7) * 44 (34.9) 4 Normal BMI values in the elderly (70 years and older) differ from those of younger individuals 76* (60.0) 20 (15.9) 30 (23.8) 5 A lower-than-normal albumin value may indicate a state of malnutrition and requires additional lab tests 103 (81.7) 18 (14.3) * 5 (4.0) 6 It's important to perform nutritional screening once a year for identifying malnutrition in the elderly using a validated screening tool * 80 (63.5) 25 (19.8) 21 (16.7) * Expected answer Insert Tables 2 and 3 about here Table 3 describes Family Physician's knowledge on the diagnosis and treatment of malnutrition in the elderly. Almost two-thirds of the respondents (63.5%) stated that they are knowledgeable in nutritional screening principles, and most (83.2%) stated that elderly people who are obese could also suffer from malnutrition. Very few (4%) agreed that low albumin levels are not necessarily an indicator of malnutrition 14 . Just over half the respondents (60 % agreed that normal body-mass index (BMI) values in the elderly differ from those in younger populations, and more than half (57.1%) agreed that Sarcopenia should be treated by referring the patient to a dietician. Additionally, almost all respondents (91%) agreed that two specific questions regarding the nutritional status of elderly patients should be an integral part of their medical visits. Moreover, the majority (71%) of physicians agreed to receive training on how to identify malnutrition and how to use a range of screening tools to detect malnutrition. No significant differences were found between the respondents by demographics. Discussion Malnutrition diagnosis and management in primary care is a significant clinical issue as recently highlighted 17,18 . Our study found that FPs recognize the importance of screening and diagnosing malnutrition in the elderly despite barriers such as lack of time, lack of knowledge, and high workload. In addition, respondents were willing to add two questions annually on screening for malnutrition risk in their elderly patients. Thus, the findings offer insights into how to overcome evidence-practice gaps such as screening, assessment, and diagnosis in primary care as indicated in the recent review 14 . Malnutrition leads to increased healthcare costs, with malnourished individuals requiring more health care professional consultations, hospitalization, health care monitoring and treatments 8 Elderly at risk of malnutrition reported having used more health care services 19 . In addition, malnutrition is associated with impaired quality of life 20 . In a study in Israel, the patients at risk of malnutrition who were admitted to an acute care hospitalization visited their FP more often during the year before hospitalization compared to those hospitalized with no risk of malnutrition 21 . Previous studies focusing on malnutrition in primary care were mostly based on qualitative research methods, which can explain some of the differences in the current study's findings. We found that FPs recognize the importance of diagnosing malnutrition compared to the evidence in the literature that suggests otherwise. In other words, FPs view malnutrition in older adults as a secondary concern compared to other higher priority issues presented by patients 22 . In line with previous studies, FPs did not agree that oral nutritional supplement is the first-line approach to treating malnutrition 23 . The barriers mentioned in this study such as a lack of time, overwhelming workload, lack of awareness and knowledge are consistent with the barriers found in other studies 24 . A Delphi study among Dutch FPs showed that the top disease-related nutrition topics were diabetes mellitus, hypercholesterolemia, and obesity, whereas nutrition problems to older people ranked as the lowest priority 25 . This reflects the historical focus in medical training where nutrition education has been traditionally used for the prevention of cardiovascular diseases 24 . Hence, the findings of the current study, where FPs gave an equal weight to the importance of treating obesity and malnutrition are impressive. Finally, to the best of our knowledge, no literature has been found regarding FPs attitudes and knowledge on interventions for Sarcopenia and appetite change, which are included in this study. We propose an algorithm (Fig. 1 ) for screening the elderly for the risk of malnutrition using two questions which have been identified as predictors or as signs of malnutrition 4 . The screening will be conducted by either the FPs, other staff members, or self-administered. If the answer to one of the questions is positive, we recommend that the physician will use the GLIM criteria to make a diagnosis of malnutrition (using the future ICD-11 classification), 1 which will be recorded in the electronic medical records of the patient. The GLIM framework states that one of the following phenotypes (weight loss, low BMI, or low-fat free mass), must be positive in conjunction with one of the two etiologies, (reduced food intake/ assimilation or disease with inflammation) in order to classify the patient as malnourished. The data relating to weight loss and BMI are written in the patients' medical records and is also part of the quality indicators which are monitored in community medicine in Israel. The etiology of disease with inflammation is known to the FPs. In relation to the etiology of reduced food intake/ assimilation, we propose using an easy tool by the physician 26 which can identify patients who consume ≤ 50% of their energy requirements in the last week or any reduction in energy requirement in more than two weeks. When the patient has a diagnosis of malnutrition by the ICD-11 classification, this diagnosis will be part of the patient’s problem list when he is seen by any other specialist or hospital. This diagnosis will be a basis for triggering a comprehensive interdisciplinary intervention based on the organizations’ policy. As most of the physicians agreed to receive training in how to use a variety of screening tools to detect the risk of malnutrition and diagnose malnutrition, we propose creating a short electronic interactive tutorial relating to the GLIM criteria framework. The main limitation of the current study is the response rate of the physicians which may introduce selection bias into the findings. It seems that the physicians who agreed to participate in the study are younger, trained in Israeli medical schools, and board-certified as FP's, which might explain the relatively higher knowledge in the area of nutrition. We believe that the level of nutritional knowledge among all FPs, is lower compared with our respondents. This highlights the potential need for a short intervention to address this knowledge gap. Improving the nutritional knowledge of FPs is crucial as they play a significant role in providing primary healthcare and in referring the malnourished elderly to a dietitian or other relevant professions for treatment. The current study is one of the first studies to use a short survey to provide a basic understanding for developing the proper intervention for FP. By utilizing a short nutritional screening, nutritional risk can be identified and followed by the GLIM to diagnose malnutrition. Of particular significance is the potential integration of this process into an artificial intelligence 27 framework, to enhance FPs' awareness regarding the nutritional status of their patients, leading to timelier interventions and improved patient outcomes. Insert Fig- 1 about here Conclusion FPs, recognize the importance of screening and diagnosing malnutrition in the elderly despite barriers such as lack of time, lack of knowledge, and high workload. In addition, respondents were willing to add two questions annually on screening for malnutrition risk in their elderly patients. Based on previous publications and our findings we propose (Fig. 1 ) a simple algorithm for nutritional intervention using GLIM and existing medical records data. The algorithm begins with screening, identifying patients at nutritional risk followed by the GLIM to diagnose malnutrition and referring malnourished patients to the proper intervention. We believe that the algorithm can be implemented into the medical records as part of preventive measures to improve the health and quality of life of the malnourished elderly patients. Declarations Ethics approval and consent to participate All participants provided informed consent. The study was approved by the Ethics Committee of. of Ben-Gurion University, Faculty of Health Sciences (06/2022). A statement to confirm that all methods were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Availability of data and material The data that support the findings of this study are available from the corresponding author on reasonable request. Funding The authors did not receive support from any organization for the submitted work Authors' contributions GSH and JK- Conception and design of the study, development of questionnaires, data collection, drafting the manuscript. DRS- Data collection or generation, data analysis and interpretation, drafting the manuscript. AB and SA- Recruitment of participants, drafting the manuscript, overview and revisions of the manuscript Acknowledgements Not applicable. References Cederholm T, Rothenberg E, Barazzoni R. A Clinically Relevant Diagnosis Code for Malnutrition in Adults Is Needed in ICD-11. J Nutr Health Aging. 2022;26(4):314–5. 10.1007/s12603-022-1774-z . Cereda E, Pedrolli C, Klersy C, et al. Nutritional status in older persons according to healthcare setting: A systematic review and meta-analysis of prevalence data using MNA®. Clin Nutr. 2016;35(6):1282–90. https://doi.org/10.1016/j.clnu.2016.03.008 . Browne S, Kelly L, Geraghty AA, et al. Healthcare professionals’ perceptions of malnutrition management and oral nutritional supplement prescribing in the community: A qualitative study. Clin Nutr ESPEN. 2021;44:415–23. https://doi.org/10.1016/j.clnesp.2021.04.024 . Norman K, Haß U, Pirlich M. Malnutrition in Older Adults—Recent Advances and Remaining Challenges. Nutrients. 2021;13(8). 10.3390/nu13082764 . Trevisan C, Crippa A, Ek S, et al. Nutritional Status, Body Mass Index, and the Risk of Falls in Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2019;20(5):569–582e7. https://doi.org/10.1016/j.jamda.2018.10.027 . Lorenzo-López L, Maseda A, de Labra C, Regueiro-Folgueira L, Rodríguez-Villamil JL, Millán-Calenti JC. Nutritional determinants of frailty in older adults: A systematic review. BMC Geriatr. 2017;17(1):108. 10.1186/s12877-017-0496-2 . Lim SL, Ong KCB, Chan YH, Loke WC, Ferguson M, Daniels L. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr. 2012;31(3):345–50. https://doi.org/10.1016/j.clnu.2011.11.001 . Elia M. The Cost of Malnutrition in England and Potential Cost Savings from Nutritional Interventions (Full Report) A Report on the Cost of Disease-Related Malnutrition in England and a Budget Impact Analysis of Implementing the NICE Clinical Guidelines/Quality Standard on Nutritional Support in Adults .; 2015. . Rea J, Walters K, Avgerinou C. How effective is nutrition education aiming to prevent or treat malnutrition in community-dwelling older adults? A systematic review. Eur Geriatr Med. 2019;10(3):339–58. 10.1007/s41999-019-00172-6 . Cardenas D. Ethical issues and dilemmas in artificial nutrition and hydration. Clin Nutr ESPEN. 2021;41:23–9. https://doi.org/10.1016/j.clnesp.2020.12.010 . Skipper A, Ferguson M, Thompson K, Castellanos VH, Porcari J. Nutrition Screening Tools. J Parenter Enter Nutr. 2012;36(3):292–8. https://doi.org/10.1177/0148607111414023 . Cederholm T, Jensen GL, Correia MITD, et al. GLIM criteria for the diagnosis of malnutrition – A consensus report from the global clinical nutrition community. J Cachexia Sarcopenia Muscle. 2019;10(1):207–17. https://doi.org/10.1002/jcsm.12383 . Cederholm T, Barazzoni R. A year with the GLIM diagnosis of malnutrition – does it work for older persons? Curr Opin Clin Nutr Metab Care. 2021;24(1). https://journals.lww.com/co-clinicalnutrition/Fulltext/2021/01000/A_year_with_the_GLIM_diagnosis_of_malnutrition__.3.aspx . Dent E, Wright ORL, Woo J, Hoogendijk EO. Malnutrition in older adults. Lancet. 2023;401(10380):951–66. 10.1016/S0140-6736(22)02612-5 . Shahar DR, Yu B, Houston DK, et al. Dietary factors in relation to daily activity energy expenditure and mortality among older adults. JNHA - J Nutr Health Aging. 2009;13(5):414–20. 10.1007/s12603-009-0077-y . Dent E, Hoogendijk EO, Wright ORL. New insights into the anorexia of ageing: from prevention to treatment. Curr Opin Clin Nutr Metab Care. 2019;22(1). https://journals.lww.com/co-clinicalnutrition/fulltext/2019/01000/new_insights_into_the_anorexia_of_ageing__from.9.aspx . Murphy J, Mayor A, Forde E. Identifying and treating older patients with malnutrition in primary care: the MUST screening tool. Br J Gen Pract. 2018;68(672):344–5. 10.3399/bjgp18X697853 . Darzi J. Be nutrition aware in primary care: making every contact count. Br J Gen Pract. 2014;64(628):554–5. 10.3399/bjgp14X682105 . ClinicoEconomics and Outcomes Research . 2020;12:355–367. doi:10.2147/CEOR.S256671. Damião R, Meneguci J, da Silva Santos Á, Matijasevich A, Rossi Menezes P. Nutritional Risk and Quality of Life in Community-Dwelling Elderly: A Cross-Sectional Study. J Nutr Health Aging. 2018;22(1):111–6. 10.1007/s12603-017-0935-y . Feldblum I, German L, Castel H, et al. Characteristics of undernourished older medical patients and the identification of predictors for undernutrition status. Nutr J. 2007;6(1):37. 10.1186/1475-2891-6-37 . Dominguez Castro P, Reynolds CME, Kennelly S, et al. General practitioners’ views on malnutrition management and oral nutritional supplementation prescription in the community: A qualitative study. Clin Nutr ESPEN. 2020;36:116–27. https://doi.org/10.1016/j.clnesp.2020.01.006 . Beelen J, Vasse E, Ziylan C, Janssen N, de Roos NM, de Groot LCPGM. Undernutrition: who cares? Perspectives of dietitians and older adults on undernutrition. BMC Nutr. 2017;3(1):24. 10.1186/s40795-017-0144-4 . Avgerinou C, Bhanu C, Walters K, et al. Supporting nutrition in frail older people: a qualitative study exploring views of primary care and community health professionals. Br J Gen Pract. 2020;70(691):e138–45. 10.3399/bjgp20X707861 . Maiburg BHJ, Rethans JJE, van Ree JW. GPs’ needs for practice-oriented nutrition education; a Delphi study among Dutch GPs. Fam Pract. 2004;21(4):425–8. 10.1093/fampra/cmh413 . Bouëtté G, Esvan M, Apel K, Thibault R. A visual analogue scale for food intake as a screening test for malnutrition in the primary care setting: Prospective non-interventional study. Clin Nutr. 2021;40(1):174–80. https://doi.org/10.1016/j.clnu.2020.04.042 . Kueper JK, Terry AL, Zwarenstein M, Lizotte DJ. Artificial Intelligence and Primary Care Research: A Scoping Review. Annals Family Med. 2020;18(3):250. 10.1370/afm.2518 . Supplementary Files Appendix1.docx Cite Share Download PDF Status: Published Journal Publication published 02 Sep, 2024 Read the published version in Israel Journal of Health Policy Research → Version 1 posted Editorial decision: Major revision 30 Mar, 2024 Reviewers agreed at journal 09 Mar, 2024 Reviewers invited by journal 06 Mar, 2024 Editor assigned by journal 06 Mar, 2024 First submitted to journal 26 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3929790","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":276703100,"identity":"0248a504-6d61-414a-8231-3e56b1a0c709","order_by":0,"name":"Galia Sheffer-Hilel","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIie3OvQrCMBSG4a8IcfFnDSjtLaS4u3obDR1cHBwdBI8IcVJvQLwJwfmUQidvortDXQRBxYoibunokHc7w5MvgMv1l9WIMQFaEuDXLepW4pXkqCC+pFaBwDNv8pm1gGCQzPm6u/mis8gZ0z5aNhIeNSWrg+qJbqYYWWz/WEiauHlQ2sioJIIrkE1OyX2rZkYOC8ajAgmkprRJKhJypNgzFYiSOaXdrBcaORqzXscN+8omTs+nqR+05XBfFJe+HyzJssK/VwQ0LBvliuVJl8vlcgFPBPc/wC7+p4QAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0001-6873-7170","institution":"Tel Hai Academic College","correspondingAuthor":true,"prefix":"","firstName":"Galia","middleName":"","lastName":"Sheffer-Hilel","suffix":""},{"id":276703101,"identity":"bf5723f9-af48-4f4d-9279-4e13472b882d","order_by":1,"name":"Josefa Kachal","email":"","orcid":"","institution":"Tel Hai Academic College","correspondingAuthor":false,"prefix":"","firstName":"Josefa","middleName":"","lastName":"Kachal","suffix":""},{"id":276703102,"identity":"ccf095ee-cdce-405b-8c81-d201dcd36626","order_by":2,"name":"Aya Biderman","email":"","orcid":"","institution":"Universitat Ben-Gurion ba'Negev: Ben-Gurion University of the Negev","correspondingAuthor":false,"prefix":"","firstName":"Aya","middleName":"","lastName":"Biderman","suffix":""},{"id":276703103,"identity":"d72c5c5a-e189-45f9-81c7-959d2bc91dc6","order_by":3,"name":"Danit Rivka Shahar","email":"","orcid":"","institution":"Universitat Ben-Gurion ba'Negev: Ben-Gurion University of the Negev","correspondingAuthor":false,"prefix":"","firstName":"Danit","middleName":"Rivka","lastName":"Shahar","suffix":""},{"id":276703104,"identity":"6c61eb29-2d06-4bcc-8bee-7841416dce05","order_by":4,"name":"Shimon Amar","email":"","orcid":"","institution":"Universitat Ben-Gurion ba'Negev: Ben-Gurion University of the Negev","correspondingAuthor":false,"prefix":"","firstName":"Shimon","middleName":"","lastName":"Amar","suffix":""}],"badges":[],"createdAt":"2024-02-05 03:54:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3929790/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3929790/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13584-024-00631-x","type":"published","date":"2024-09-02T16:08:31+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":52302374,"identity":"da0813ce-619a-480e-a5fe-d12500df65a4","added_by":"auto","created_at":"2024-03-08 18:46:00","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":67134,"visible":true,"origin":"","legend":"\u003cp\u003eMalnutrition Assessment Framework in Primary Care\u003c/p\u003e","description":"","filename":"Malnutritionalgo.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3929790/v1/5ba5bc357d14bbf5597183e9.jpg"},{"id":64186206,"identity":"f72a1f97-88b9-4ee4-b35c-ba7eff857196","added_by":"auto","created_at":"2024-09-09 16:25:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":515060,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3929790/v1/79092666-61b1-4970-b0bc-04039ffc26b9.pdf"},{"id":52302375,"identity":"8245a1fb-c8e1-40ba-bc11-3669b8f03239","added_by":"auto","created_at":"2024-03-08 18:46:00","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":15432,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3929790/v1/c84684fc0375e428136c9aba.docx"}],"financialInterests":"","formattedTitle":"The Attitudes and Knowledge of Family Physicians Regarding Malnutrition in The Elderly: A Call for Action","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMalnutrition is a complex condition that has numerous etiologies, that may develop independently or following the interaction between food deprivation and catabolic processes that are linked to disease-related inflammation\u003csup\u003e1\u003c/sup\u003e. In general, it is estimated that 5\u0026ndash;26% of older adults are at risk of malnutrition\u003csup\u003e2\u003c/sup\u003e. Older adults, aged 70 years and above, are at even higher risk, due to a range of physiological and social factors, such as frailty, reduced appetite, sensory impairments, poor dentition, swallowing problems, depression, dementia, and even social isolation\u003csup\u003e3\u003c/sup\u003e. Malnutrition could have serious consequences on the individual, such as impaired healing of wounds, reduced immunity\u003csup\u003e4\u003c/sup\u003e, higher risk of falls\u003csup\u003e5\u003c/sup\u003e, impaired functionality\u003csup\u003e6\u003c/sup\u003e, increased mortality risks\u003csup\u003e7\u003c/sup\u003e, and decreased quality of life\u003csup\u003e8\u003c/sup\u003e. The burden of malnutrition on health care is significant, taking a toll on resources such as expenses and manpower\u003csup\u003e9\u003c/sup\u003e. According to the recent Vienna Declaration, nutritional care is an emerging human right, in line with the understanding that nutrition is a fundamental aspect of health and well-being. Moreover, it lies at the intersection of the existing human rights to food and to health, i.e., \u0026ldquo;the right to be fed\u0026rdquo;\u003csup\u003e10\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFamily Physicians (FP) working in the community serve as the initial point of contact for patients within the healthcare system, therefore, they are ideally positioned to identify patients with malnutrition and refer them to other health care professionals for further assessment and treatment. Although malnutrition in the elderly is a global concern, a fundamental lack of consensus can be seen regarding the criteria for diagnosing malnutrition in clinical settings. The International Classifications of Diseases (ICD) focuses on identifying nutrient deprivation and deficiency.\u003csup\u003e1\u003c/sup\u003e However, the clinical settings and snapshot of global malnutrition has greatly evolved over time, becoming even more complex and intricate. Indeed, this is expected to be addressed in the next ICD to be issued, to provide the clinical nutrition community with more specific coding regarding malnutrition in adults \u0026ndash; one that reflects current malnutrition perceptions and may support clinical decision-making in everyday practice\u003csup\u003e1\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTo adequately and accurately diagnose and document malnutrition in medical records, reliable and valid diagnostic tools are needed\u003csup\u003e11\u003c/sup\u003e. One such tool that encompasses the expertise of several nutritional societies is the Global Leadership Initiative on Malnutrition (GLIM) \u0026ndash; a global consensus on core criteria for diagnosing malnutrition in adults in all health care settings\u003csup\u003e12\u003c/sup\u003e. The GLIM diagnostic framework is currently being validated for older populations across a variety of settings and clinical conditions\u003csup\u003e13\u003c/sup\u003e. Yet, a recent review of the current literature on identification and treatment of malnutrition in older adults identifies gaps between research evidence clinical practice\u003csup\u003e14\u003c/sup\u003e. This study aimed at examining such gaps in Israel, by assessing FPs\u0026rsquo; knowledge and attitudes toward malnutrition diagnosis and treatment in the elderly, with an emphasis on barriers in the use of this diagnostic tool for identifying elderly patients with malnutrition in Israel.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSubjects and Research Design\u003c/h2\u003e \u003cp\u003eIn 2022, an online survey was sent to FPs from the four main health maintenance organizations (HMOs) in Israel. To increase the response rate, the questionnaire was kept as short as possible (5\u0026ndash;10 minutes to complete). The electronic questionnaire included seven statements regarding the FPs\u0026rsquo; attitudes towards diagnosing and treating malnutrition in the elderly and six statements regarding their knowledge of these topics. For each of the 15 items included in the questionnaire, the respondents were asked to choose their degree of agreement, from the following five options: 1) completely agree; 2) agree; 3) partially agree; 4) disagree; or 5) completely disagree (Appendix 1).\u003c/p\u003e \u003cp\u003eAdditional questions were included in the survey regarding barriers and willingness to screen for malnutrition; the respondents were also asked to provide demographic data, including gender, age, years of experience as a physician (including specialization in family medicine), number of years of experience as board certified family physicians, region of practice (north south), type of clinic (urban, rural, or both), and whether there is a dietician at their clinic. A total of about 300 physicians were approached to participate in this study, recruited through three channels: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) National on-line network of FPs; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) e-mail sent to all FP's who work in the southern region of the country; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) during a large conference for FP's. The respondents provided their informed consent prior to completing the questionnaire. The study was approved by the Ethics Committee of. of Ben-Gurion University, Faculty of Health Sciences (06/2022).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eQuestionnaire Development\u003c/h2\u003e \u003cp\u003eThe focus of the questionnaire is nutritional screening, diagnosing and treating malnutrition. A review of the literature was conducted to provide initial direction for creating the survey, with the included items and questions being related to the various topics that emerged from this review. Moreover, an emphasis was placed on two of the most consistent risk factors for malnutrition: involuntary weight loss and decreased appetite; In addition, we asked about Sarcopenia \u0026ndash; a nutritional disorder which is frequently overlooked in elderly patients\u003csup\u003e4,15,16\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData analysis was conducted using SPSS v. 27.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to depict the respondents\u0026rsquo; level of agreement with each of the statements, using the three following categories: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) \u0026lsquo;agree\u0026rsquo; (a combination of \u003cem\u003ecompletely agree\u003c/em\u003e and \u003cem\u003eagree\u003c/em\u003e); (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) \u0026lsquo;partially agree\u0026rsquo;; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) \u0026lsquo;disagree\u0026rsquo; (a combination of \u003cem\u003ecompletely disagree\u003c/em\u003e and \u003cem\u003edisagree\u003c/em\u003e). Chi square was calculated to compare responses by gender and years of experience.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 126 physicians participated in the study (67% females). As seen in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, their mean age was 47.2 years (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6), Most were board certified family physicians (92%) who had studied medicine in Israel (75%). The mean number of total years of experience as a physician was 15.6 years (SD 12.5) and as a FP 10.2 years (SD 11.3).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRespondents\u0026rsquo; demographic characteristics (N\u0026thinsp;=\u0026thinsp;126)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eData\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM(SD)\u0026thinsp;=\u0026thinsp;47.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemales\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;84 (67%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;112 (92%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudied medicine in Israel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;94 (75%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of experience as physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM(SD)\u0026thinsp;=\u0026thinsp;15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;12.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of experience as Family physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM(SD)\u0026thinsp;=\u0026thinsp;10.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eInsert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e about here\u003c/h2\u003e \u003cp\u003eAs seen in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, most FP's (92.7%) agreed that diagnosing malnutrition is important. Similarly, most FPs (77.6%) agreed that in elderly patients with decreased appetite, nutritional assessments are necessary. However, only about one-third (35.2%) stated that they have adequate knowledge in the field of nutrition, and less than half (46.4%) stated that nutritional screening should be performed by nurses rather than by physicians. About one-third (35.5%) agreed that involuntary weight loss should be treated with oral nutritional supplement (ONS). Finally, 38.9% of the respondents attributed lack of time and lack of personnel as barriers in screening for malnutrition.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAttitudes of family physicians towards diagnosing and treating malnutrition in the elderly\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFully agree\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePartially agree\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn my opinion, the knowledge I have in the field of nutrition is sufficient to help my elderly patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33 (26.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44 (35.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e48 (38.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIt's more important to treat obesity than malnutrition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e110 (87.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIt's important to identify malnutrition in elderly patients, to improve their quality of life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e117 (92.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScreening for malnutrition in the elderly should be performed by nurses, who should refer them to a dietician if needed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58 (46.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44 (35.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23 (18.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhen patients report a loss of appetite, they should undergo a nutritional assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e97 (77.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8 (6.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhen elderly patients report having lost 2\u0026ndash;3 kilograms in three months, the physician should recommend that they consume oral nutritional supplements, such as Ensure or Nutren\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44 (35.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e68 (54.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCarrying out nutritional screening of elderly patients in the clinic is not possible, due to lack of time and personnel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49 (38.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37 (29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e40 (31.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKnowledge of family physicians regarding diagnosing and treating malnutrition in the elderly\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFully agree\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePartially agree\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElderly people who are obese cannot suffer from malnutrition as well\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14 (11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e*104 (83.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhen an elderly patient is in a state of sarcopenia (loss of muscle strength and muscle mass), I refer him/her to a dietician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72\u003cb\u003e*\u003c/b\u003e (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOlder patients who are overweight should be encouraged to lose weight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40 (31.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e*\u003c/b\u003e44 (34.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal BMI values in the elderly (70 years and older) differ from those of younger individuals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e76* (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20 (15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30 (23.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA lower-than-normal albumin value may indicate a state of malnutrition and requires additional lab tests\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e103 (81.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e*\u003c/b\u003e5 (4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIt's important to perform nutritional screening once a year for identifying malnutrition in the elderly using a validated screening tool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e*\u003c/b\u003e80 (63.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25 (19.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003e* Expected answer\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003ch2\u003eInsert Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e about here\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e describes Family Physician's knowledge on the diagnosis and treatment of malnutrition in the elderly. Almost two-thirds of the respondents (63.5%) stated that they are knowledgeable in nutritional screening principles, and most (83.2%) stated that elderly people who are obese could also suffer from malnutrition. Very few (4%) agreed that low albumin levels are \u003cem\u003enot\u003c/em\u003e necessarily an indicator of malnutrition\u003csup\u003e14\u003c/sup\u003e. Just over half the respondents (60 % agreed that normal body-mass index (BMI) values in the elderly differ from those in younger populations, and more than half (57.1%) agreed that Sarcopenia should be treated by referring the patient to a dietician. Additionally, almost all respondents (91%) agreed that two specific questions regarding the nutritional status of elderly patients should be an integral part of their medical visits. Moreover, the majority (71%) of physicians agreed to receive training on how to identify malnutrition and how to use a range of screening tools to detect malnutrition. No significant differences were found between the respondents by demographics.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eMalnutrition diagnosis and management in primary care is a significant clinical issue as recently highlighted\u003csup\u003e17,18\u003c/sup\u003e. Our study found that FPs recognize the importance of screening and diagnosing malnutrition in the elderly despite barriers such as lack of time, lack of knowledge, and high workload. In addition, respondents were willing to add two questions annually on screening for malnutrition risk in their elderly patients. Thus, the findings offer insights into how to overcome evidence-practice gaps such as screening, assessment, and diagnosis in primary care as indicated in the recent review\u003csup\u003e14\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eMalnutrition leads to increased healthcare costs, with malnourished individuals requiring more health care professional consultations, hospitalization, health care monitoring and treatments\u003csup\u003e8\u003c/sup\u003e Elderly at risk of malnutrition reported having used more health care services\u003csup\u003e19\u003c/sup\u003e. In addition, malnutrition is associated with impaired quality of life\u003csup\u003e20\u003c/sup\u003e. In a study in Israel, the patients at risk of malnutrition who were admitted to an acute care hospitalization visited their FP more often during the year before hospitalization compared to those hospitalized with no risk of malnutrition\u003csup\u003e21\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePrevious studies focusing on malnutrition in primary care were mostly based on qualitative research methods, which can explain some of the differences in the current study's findings. We found that FPs recognize the importance of diagnosing malnutrition compared to the evidence in the literature that suggests otherwise. In other words, FPs view malnutrition in older adults as a secondary concern compared to other higher priority issues presented by patients\u003csup\u003e22\u003c/sup\u003e. In line with previous studies, FPs did not agree that oral nutritional supplement is the first-line approach to treating malnutrition\u003csup\u003e23\u003c/sup\u003e. The barriers mentioned in this study such as a lack of time, overwhelming workload, lack of awareness and knowledge are consistent with the barriers found in other studies\u003csup\u003e24\u003c/sup\u003e. A Delphi study among Dutch FPs showed that the top disease-related nutrition topics were diabetes mellitus, hypercholesterolemia, and obesity, whereas nutrition problems to older people ranked as the lowest priority\u003csup\u003e25\u003c/sup\u003e. This reflects the historical focus in medical training where nutrition education has been traditionally used for the prevention of cardiovascular diseases\u003csup\u003e24\u003c/sup\u003e. Hence, the findings of the current study, where FPs gave an equal weight to the importance of treating obesity and malnutrition are impressive. Finally, to the best of our knowledge, no literature has been found regarding FPs attitudes and knowledge on interventions for Sarcopenia and appetite change, which are included in this study.\u003c/p\u003e \u003cp\u003eWe propose an algorithm (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) for screening the elderly for the risk of malnutrition using two questions which have been identified as predictors or as signs of malnutrition\u003csup\u003e4\u003c/sup\u003e. The screening will be conducted by either the FPs, other staff members, or self-administered. If the answer to one of the questions is positive, we recommend that the physician will use the GLIM criteria to make a diagnosis of malnutrition (using the future ICD-11 classification),\u003csup\u003e1\u003c/sup\u003e which will be recorded in the electronic medical records of the patient. The GLIM framework states that one of the following phenotypes (weight loss, low BMI, or low-fat free mass), must be positive in conjunction with one of the two etiologies, (reduced food intake/ assimilation or disease with inflammation) in order to classify the patient as malnourished. The data relating to weight loss and BMI are written in the patients' medical records and is also part of the quality indicators which are monitored in community medicine in Israel. The etiology of disease with inflammation is known to the FPs. In relation to the etiology of reduced food intake/ assimilation, we propose using an easy tool by the physician\u003csup\u003e26\u003c/sup\u003e which can identify patients who consume\u0026thinsp;\u0026le;\u0026thinsp;50% of their energy requirements in the last week or any reduction in energy requirement in more than two weeks. When the patient has a diagnosis of malnutrition by the ICD-11 classification, this diagnosis will be part of the patient\u0026rsquo;s problem list when he is seen by any other specialist or hospital. This diagnosis will be a basis for triggering a comprehensive interdisciplinary intervention based on the organizations\u0026rsquo; policy. As most of the physicians agreed to receive training in how to use a variety of screening tools to detect the risk of malnutrition and diagnose malnutrition, we propose creating a short electronic interactive tutorial relating to the GLIM criteria framework.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe main limitation of the current study is the response rate of the physicians which may introduce selection bias into the findings. It seems that the physicians who agreed\u003c/p\u003e \u003cp\u003eto participate in the study are younger, trained in Israeli medical schools, and board-certified as FP's, which might explain the relatively higher knowledge in the area of nutrition. We believe that the level of nutritional knowledge among all FPs, is lower compared with our respondents. This highlights the potential need for a short intervention to address this knowledge gap. Improving the nutritional knowledge of FPs is crucial as they play a significant role in providing primary healthcare and in referring the malnourished elderly to a dietitian or other relevant professions for treatment.\u003c/p\u003e \u003cp\u003eThe current study is one of the first studies to use a short survey to provide a basic understanding for developing the proper intervention for FP. By utilizing a short\u003c/p\u003e \u003cp\u003enutritional screening, nutritional risk can be identified and followed by the GLIM to diagnose malnutrition. Of particular significance is the potential integration of this process into an artificial intelligence\u003csup\u003e27\u003c/sup\u003e framework, to enhance FPs' awareness regarding the nutritional status of their patients, leading to timelier interventions and improved patient outcomes.\u003c/p\u003e\n\u003ch3\u003eInsert Fig- 1 about here\u003c/h3\u003e\n"},{"header":"Conclusion","content":"\u003cp\u003eFPs, recognize the importance of screening and diagnosing malnutrition in the elderly despite barriers such as lack of time, lack of knowledge, and high workload. In addition, respondents were willing to add two questions annually on screening for malnutrition risk in their elderly patients. Based on previous publications and our findings we propose (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) a simple algorithm for nutritional intervention using GLIM and existing medical records data. The algorithm begins with screening, identifying patients at nutritional risk followed by the GLIM to diagnose malnutrition and referring malnourished patients to the proper intervention. We believe that the algorithm can be implemented into the medical records as part of preventive measures to improve the health and quality of life of the malnourished elderly patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003eAll participants provided informed consent. The study was approved by the Ethics Committee of. of Ben-Gurion University, Faculty of Health Sciences (06/2022).\u0026nbsp;A\u0026nbsp;statement to confirm that all methods were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u0026nbsp;Not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003eThe data that support the findings of this study are available from the corresponding author on reasonable request. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003eThe authors did not receive support from any organization for the submitted work\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003eGSH and JK- Conception and design of the study, development of questionnaires, data collection, drafting the manuscript. DRS- Data collection or generation, data analysis and interpretation, drafting the manuscript. AB and SA- Recruitment of participants, drafting the manuscript, overview and revisions of the manuscript\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp dir=\"LTR\"\u003e\u0026nbsp;Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCederholm T, Rothenberg E, Barazzoni R. A Clinically Relevant Diagnosis Code for Malnutrition in Adults Is Needed in ICD-11. J Nutr Health Aging. 2022;26(4):314\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12603-022-1774-z\u003c/span\u003e\u003cspan address=\"10.1007/s12603-022-1774-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCereda E, Pedrolli C, Klersy C, et al. Nutritional status in older persons according to healthcare setting: A systematic review and meta-analysis of prevalence data using MNA\u0026reg;. Clin Nutr. 2016;35(6):1282\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.clnu.2016.03.008\u003c/span\u003e\u003cspan address=\"10.1016/j.clnu.2016.03.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrowne S, Kelly L, Geraghty AA, et al. Healthcare professionals\u0026rsquo; perceptions of malnutrition management and oral nutritional supplement prescribing in the community: A qualitative study. Clin Nutr ESPEN. 2021;44:415\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.clnesp.2021.04.024\u003c/span\u003e\u003cspan address=\"10.1016/j.clnesp.2021.04.024\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorman K, Ha\u0026szlig; U, Pirlich M. Malnutrition in Older Adults\u0026mdash;Recent Advances and Remaining Challenges. Nutrients. 2021;13(8). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/nu13082764\u003c/span\u003e\u003cspan address=\"10.3390/nu13082764\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrevisan C, Crippa A, Ek S, et al. Nutritional Status, Body Mass Index, and the Risk of Falls in Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2019;20(5):569\u0026ndash;582e7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jamda.2018.10.027\u003c/span\u003e\u003cspan address=\"10.1016/j.jamda.2018.10.027\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLorenzo-L\u0026oacute;pez L, Maseda A, de Labra C, Regueiro-Folgueira L, Rodr\u0026iacute;guez-Villamil JL, Mill\u0026aacute;n-Calenti JC. Nutritional determinants of frailty in older adults: A systematic review. BMC Geriatr. 2017;17(1):108. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12877-017-0496-2\u003c/span\u003e\u003cspan address=\"10.1186/s12877-017-0496-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLim SL, Ong KCB, Chan YH, Loke WC, Ferguson M, Daniels L. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr. 2012;31(3):345\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.clnu.2011.11.001\u003c/span\u003e\u003cspan address=\"10.1016/j.clnu.2011.11.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElia M. \u003cem\u003eThe Cost of Malnutrition in England and Potential Cost Savings from Nutritional Interventions (Full Report) A Report on the Cost of Disease-Related Malnutrition in England and a Budget Impact Analysis of Implementing the NICE Clinical Guidelines/Quality Standard on Nutritional Support in Adults\u003c/em\u003e.; 2015. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.bapen.org.uk\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRea J, Walters K, Avgerinou C. How effective is nutrition education aiming to prevent or treat malnutrition in community-dwelling older adults? A systematic review. Eur Geriatr Med. 2019;10(3):339\u0026ndash;58. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s41999-019-00172-6\u003c/span\u003e\u003cspan address=\"10.1007/s41999-019-00172-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCardenas D. Ethical issues and dilemmas in artificial nutrition and hydration. Clin Nutr ESPEN. 2021;41:23\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.clnesp.2020.12.010\u003c/span\u003e\u003cspan address=\"10.1016/j.clnesp.2020.12.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkipper A, Ferguson M, Thompson K, Castellanos VH, Porcari J. Nutrition Screening Tools. J Parenter Enter Nutr. 2012;36(3):292\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0148607111414023\u003c/span\u003e\u003cspan address=\"10.1177/0148607111414023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCederholm T, Jensen GL, Correia MITD, et al. GLIM criteria for the diagnosis of malnutrition \u0026ndash; A consensus report from the global clinical nutrition community. J Cachexia Sarcopenia Muscle. 2019;10(1):207\u0026ndash;17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/jcsm.12383\u003c/span\u003e\u003cspan address=\"10.1002/jcsm.12383\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCederholm T, Barazzoni R. A year with the GLIM diagnosis of malnutrition \u0026ndash; does it work for older persons? Curr Opin Clin Nutr Metab Care. 2021;24(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://journals.lww.com/co-clinicalnutrition/Fulltext/2021/01000/A_year_with_the_GLIM_diagnosis_of_malnutrition__.3.aspx\u003c/span\u003e\u003cspan address=\"https://journals.lww.com/co-clinicalnutrition/Fulltext/2021/01000/A_year_with_the_GLIM_diagnosis_of_malnutrition__.3.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDent E, Wright ORL, Woo J, Hoogendijk EO. Malnutrition in older adults. Lancet. 2023;401(10380):951\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(22)02612-5\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(22)02612-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShahar DR, Yu B, Houston DK, et al. Dietary factors in relation to daily activity energy expenditure and mortality among older adults. JNHA - J Nutr Health Aging. 2009;13(5):414\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12603-009-0077-y\u003c/span\u003e\u003cspan address=\"10.1007/s12603-009-0077-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDent E, Hoogendijk EO, Wright ORL. New insights into the anorexia of ageing: from prevention to treatment. Curr Opin Clin Nutr Metab Care. 2019;22(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://journals.lww.com/co-clinicalnutrition/fulltext/2019/01000/new_insights_into_the_anorexia_of_ageing__from.9.aspx\u003c/span\u003e\u003cspan address=\"https://journals.lww.com/co-clinicalnutrition/fulltext/2019/01000/new_insights_into_the_anorexia_of_ageing__from.9.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurphy J, Mayor A, Forde E. Identifying and treating older patients with malnutrition in primary care: the MUST screening tool. Br J Gen Pract. 2018;68(672):344\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3399/bjgp18X697853\u003c/span\u003e\u003cspan address=\"10.3399/bjgp18X697853\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDarzi J. Be nutrition aware in primary care: making every contact count. Br J Gen Pract. 2014;64(628):554\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3399/bjgp14X682105\u003c/span\u003e\u003cspan address=\"10.3399/bjgp14X682105\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eClinicoEconomics and Outcomes Research\u003c/em\u003e. 2020;12:355\u0026ndash;367. doi:10.2147/CEOR.S256671.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDami\u0026atilde;o R, Meneguci J, da Silva Santos \u0026Aacute;, Matijasevich A, Rossi Menezes P. Nutritional Risk and Quality of Life in Community-Dwelling Elderly: A Cross-Sectional Study. J Nutr Health Aging. 2018;22(1):111\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12603-017-0935-y\u003c/span\u003e\u003cspan address=\"10.1007/s12603-017-0935-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeldblum I, German L, Castel H, et al. Characteristics of undernourished older medical patients and the identification of predictors for undernutrition status. Nutr J. 2007;6(1):37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1475-2891-6-37\u003c/span\u003e\u003cspan address=\"10.1186/1475-2891-6-37\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDominguez Castro P, Reynolds CME, Kennelly S, et al. General practitioners\u0026rsquo; views on malnutrition management and oral nutritional supplementation prescription in the community: A qualitative study. Clin Nutr ESPEN. 2020;36:116\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.clnesp.2020.01.006\u003c/span\u003e\u003cspan address=\"10.1016/j.clnesp.2020.01.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeelen J, Vasse E, Ziylan C, Janssen N, de Roos NM, de Groot LCPGM. Undernutrition: who cares? Perspectives of dietitians and older adults on undernutrition. BMC Nutr. 2017;3(1):24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s40795-017-0144-4\u003c/span\u003e\u003cspan address=\"10.1186/s40795-017-0144-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAvgerinou C, Bhanu C, Walters K, et al. Supporting nutrition in frail older people: a qualitative study exploring views of primary care and community health professionals. Br J Gen Pract. 2020;70(691):e138\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3399/bjgp20X707861\u003c/span\u003e\u003cspan address=\"10.3399/bjgp20X707861\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaiburg BHJ, Rethans JJE, van Ree JW. GPs\u0026rsquo; needs for practice-oriented nutrition education; a Delphi study among Dutch GPs. Fam Pract. 2004;21(4):425\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/fampra/cmh413\u003c/span\u003e\u003cspan address=\"10.1093/fampra/cmh413\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBou\u0026euml;tt\u0026eacute; G, Esvan M, Apel K, Thibault R. A visual analogue scale for food intake as a screening test for malnutrition in the primary care setting: Prospective non-interventional study. Clin Nutr. 2021;40(1):174\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.clnu.2020.04.042\u003c/span\u003e\u003cspan address=\"10.1016/j.clnu.2020.04.042\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKueper JK, Terry AL, Zwarenstein M, Lizotte DJ. Artificial Intelligence and Primary Care Research: A Scoping Review. Annals Family Med. 2020;18(3):250. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1370/afm.2518\u003c/span\u003e\u003cspan address=\"10.1370/afm.2518\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"israel-journal-of-health-policy-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jhpr","sideBox":"Learn more about [Israel Journal of Health Policy Research](http://ijhpr.biomedcentral.com/)","snPcode":"13584","submissionUrl":"https://www.editorialmanager.com/jhpr/default2.aspx","title":"Israel Journal of Health Policy Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Malnutrition, Elderly, Family physician, GLIM","lastPublishedDoi":"10.21203/rs.3.rs-3929790/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3929790/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMalnutrition in the elderly places a significant burden on healthcare, social, and aged-care systems, yet it often remains undiagnosed and untreated. This study aims to evaluate family physicians' knowledge and attitudes towards the diagnosis and treatment of malnutrition in the elderly.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eBased on a literature review, an online questionnaire was developed, comprised of seven knowledge-related items and eight attitude-related questions regarding malnutrition in elderly populations. We also assessed the feasibility of including two malnutrition screening questions in regular clinic visits for individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;70 years.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSurveys were completed by 126 physicians (35% response rate), mean age 47.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6 years; 15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;12.5 years of practice; 67% females; and 92% board-certified family physicians. Moreover, 77.6% agreed that diagnosing malnutrition is important in patients with decreased appetite. Most respondents demonstrated knowledge of nutritional screening principles (63.5%) and recognized that even obese elderly individuals could be malnourished (83.2%). There was partial agreement (60%) that normal BMI values in the elderly differ from those in younger populations. Almost complete agreement was seen for incorporating two nutritional status questions in medical visits (91%), with physicians expressing willingness to receive training in malnutrition identification and screening tools. Despite challenges such as time constraints and limited knowledge, participants were open to conducting biannual malnutrition risk screening for elderly patients.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWe therefore recommend malnutrition diagnosis based on the Global Leadership Initiative on Malnutrition (GLIM) criteria and utilizing existing medical records, into primary care practices. This could be further enhanced through artificial intelligence, increasing awareness of malnutrition among family physicians.\u003c/p\u003e","manuscriptTitle":"The Attitudes and Knowledge of Family Physicians Regarding Malnutrition in The Elderly: A Call for Action","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-08 18:45:56","doi":"10.21203/rs.3.rs-3929790/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2024-03-30T12:52:59+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-03-09T16:41:56+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-06T09:32:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-06T05:13:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Israel Journal of Health Policy Research","date":"2024-02-27T03:11:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"israel-journal-of-health-policy-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jhpr","sideBox":"Learn more about [Israel Journal of Health Policy Research](http://ijhpr.biomedcentral.com/)","snPcode":"13584","submissionUrl":"https://www.editorialmanager.com/jhpr/default2.aspx","title":"Israel Journal of Health Policy Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8ca4c1e0-fde2-4d94-a107-c500cb964ae0","owner":[],"postedDate":"March 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-09T16:18:07+00:00","versionOfRecord":{"articleIdentity":"rs-3929790","link":"https://doi.org/10.1186/s13584-024-00631-x","journal":{"identity":"israel-journal-of-health-policy-research","isVorOnly":false,"title":"Israel Journal of Health Policy Research"},"publishedOn":"2024-09-02 16:08:31","publishedOnDateReadable":"September 2nd, 2024"},"versionCreatedAt":"2024-03-08 18:45:56","video":"","vorDoi":"10.1186/s13584-024-00631-x","vorDoiUrl":"https://doi.org/10.1186/s13584-024-00631-x","workflowStages":[]},"version":"v1","identity":"rs-3929790","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3929790","identity":"rs-3929790","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}