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Abstract
Objectives Disease-related malnutrition (DRM) presents in up to half of adults and one-third of children admitted to Canadian hospitals and significantly impacts health outcomes. Strategies to screen, diagnose and treat DRM exist but policy to facilitate implementation and sustainability are lacking. The purpose of this study was to explore gaps, opportunities, barriers and enablers for DRM policy in Canada.
Methods A qualitative study was conducted with multi-national key informants in DRM and/or health policy. Purposive sampling identified participants for a semi-structured interview. The health policy triangle framework informs policy outcomes by considering actors, content, context and processes, and was used to guide this work. Inductive thematic analysis was completed, followed by deductive analysis based on the framework.
Results DRM policy actors were seen as champions in healthcare, senior leaders in healthcare administration and individuals with lived experience. Policy content focused on screening, diagnosis and treatment of DRM. Key areas related to policy context included system specifics related to setting, cost and capacity, and social determinants of health. DRM policy processes were viewed as cross-sectoral and multi-level governance, mandating and other reinforcement strategies, windows of opportunity, and evaluation and research.
Conclusions DRM care has advanced substantially, yet policy-level changes are sparse, and gaps exist. DRM policy is facilitated by similar content around the globe and needs to be tailored to address setting-specific needs. Actors, content, context and processes inform policy and can be a dominant lever to accelerate nutrition care best practices.
- Malnutrition
- Nutrition assessment
Data availability statement
No data are available. Data are transcripts of key informant interviews and contain personally identifying information thus cannot be shared publicly.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
The impact of policy on disease related malnutrition is relatively unexplored.
WHAT THIS STUDY ADDS
Policy considerations include consistent content related to processes in support of DRM in specific settings and is supported by champions in health care, senior leaders and individuals with lived experience.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Policy can be a lever to accelerate nutrition care best practices
Introduction
Disease-related malnutrition (DRM) occurs when a patient’s energy and nutrient intake is inadequate for their physiological requirements and is often exacerbated by a systemic inflammatory response. It is associated with poor outcomes (eg, functional decline, complications, hospital readmissions and mortality) and incurs increased healthcare costs.1–3 DRM presents in up to half of Canadian adults and one-third of children admitted to hospital for ≥2 days.4 In the community, DRM affects 3%–8.5%5 of the population and has a disproportionate effect on older adults and those in seniors’ care.6 7 Strategies to address DRM exist, yet policy approaches or frameworks to support implementation are lacking in Canadian health systems.
In the past two decades, several initiatives have progressed DRM identification and treatment. A worldwide initiative (nutritionDay) has advocated for a 1-day audit every year for the past 20 years to assess malnutrition in patients across settings.8 In 2014, the Optimal Nutrition Care for All campaign (ONCA) was launched by the European Nutrition for Health Alliance to develop and implement patient-driven improved nutrition care practices in Europe.9 In 2016, the Global Leadership Initiative on Malnutrition (GLIM) built a global consensus on criteria to diagnose DRM in adults in clinical settings.10 11 Also in 2016, the United Nations General Assembly proclaimed the Decade of Action on Nutrition (2016–2025).12 In Canada, the Health Standards Organization published the Malnutrition Prevention, Detection and Treatment CAN/HSO 5066:2021(E) standard to improve patient nutrition care.13 To further advance evidence-based practices and advocate for DRM policies, the Canadian Nutrition Society and the Canadian Malnutrition Task Force registered a commitment to the United Nations Decade of Action on Nutrition14 for policy approaches to address DRM called CANDReaM (Creating Alliances Nationally for policy to address Disease Related Malnutrition). These initiatives were led by DRM champions (dedicated individuals who drive implementation efforts15) and have created awareness of nutrition as an integral component of patient care, yet DRM remains under-recognised and under-treated.
There is a lack of health policy related to undernutrition and DRM in Canada and globally. Several definitions for health policy exist and include plans, decisions, law, regulation, procedures, organisational and behaviour change to promote improvements in health. The WHO defines health policy as decisions, plans and actions that are undertaken to achieve specific healthcare goals within a society.16 The Centers for Disease Control and Prevention defines policy as law, regulation, procedure, administrative action, incentive, or voluntary practice of governments and other institutions, where health policy more specifically influences systems development, organisational change and individual behaviour to promote improvements in health.17
The health policy triangle (HPT) framework was designed for the examination of health policies and considers four areas related to policy development and implementation: actors, content, context and processes.18 19 The HPT framework was developed to emphasise the importance of moving beyond the content of a policy, to consider the actors across levels who are needed to influence policy, the processes required for developing and implementing change, and the broader context of policy.19 These four components of the HPT framework are inter-related, impact one another, and are more likely to inform policy outcomes and the effectiveness of health policy change.19 Health policy is needed to facilitate prevention, detection and treatment of DRM in Canada and improve health outcomes for at-risk patients at health system levels. Thus, the purpose of this study was to conduct key informant (KI) interviews to explore gaps, opportunities, barriers and enablers to the development and implementation of DRM health policy in Canada.
Methods
This qualitative study consisted of KI interviews with multi-national DRM and/or health policy experts. The study was part of the larger CANDReaM commitment that also includes a scoping review and environmental scan of existing DRM policies.14 Reporting was guided by the Consolidated Criteria for Reporting Qualitative Research.20
Purposive sampling21 was used to recruit KIs from different roles or disciplines (eg, academia, health systems, governments, not-for-profit organisations, industry and patient groups) and from different geographic locations across Canada and internationally. Members of the Canadian Malnutrition Task Force and coauthors suggested KIs to approach from different communities of practice, including international groups. Additional KIs were recruited using snowball sampling21 whereby participants suggested other KIs to approach for the study.
Interviews were held over videoconference between March and June 2023. Two members of the research team (LG and KLF) with knowledge and experience in DRM were present. One researcher (LG) conducted the interview while the other (KLF) took notes. A semi-structured interview guide (online supplemental file 1) was created (by LG and KLF with input from all authors) around elements of the HPT framework to help identify actors, content, context and processes for DRM policy.19 Questions sought to better understand KIs’ professional role in DRM, experiences with DRM in clinical practice, health administration and policy making, DRM policy adoption and implementation, and key DRM policy measures.
Supplemental material
Data analysis
Interviews were audio recorded and transcribed verbatim. Qualitative data were managed and analysed with the support of NVivo software (QSR International, V.12). Analysis happened concurrent to the interviews to enhance rigour and support ongoing refinement of the questions and themes through researcher responsiveness.22 Thematic analysis was applied to the transcripts and an inductive, followed by deductive, approach was used.22 Reflexive thematic analysis is a flexible, six-phase method for analysing qualitative data that begins with data familiarisation and ends with detailed reporting of patterns (ie, themes).23 24 Two members of the research team (LG and KLF) led the analysis with support from an experienced qualitative researcher (MQ). The researchers acknowledge that their expertise (LG: MD with >30 years of nutrition support and leadership experience; KLF: PhD, registered dietitian (RD); MQ: PhD, RD) and prior knowledge of some interviewees (LG) was relevant for the interviews and analysis process. All coauthors have a vested interest in advancing DRM policy development and implementation and most coauthors (KLF, RN, CB-H, CL, HK, LG) serve on the Canadian Malnutrition Task Force Advisory Committee.
Themes were iteratively developed, reviewed, discussed (by LG, KLF and MQ) and verified by all members of the research team. Findings initially appeared vast, thus an inductive approach was used to analyse the first seven transcripts to ensure that the broad nature of the data was captured.22 As potential themes were identified, it became clear that these inductive themes aligned well with the HPT framework.18 19 Given that the HPT framework had informed the study rationale and development of the interview guide, the researchers adopted the HPT framework to guide the remaining interviews and conducted deductive data analysis.19 25 Using a deductive approach for the remaining interviews allowed the research team to proceed with data analysis and frame the findings purposefully using the HPT framework.18 19 Thus, descriptive subthemes related to policy development and implementation were grouped by the categories of actors, content, context and process to align with this framework.18 19
Results
22 interviews were conducted and included 25 KIs from seven countries across four regions (North America n=14; Middle East n=2; Europe n=7; Global n=1; did not disclose n=1). 19 discussions were conducted as one-on-one interviews and three were carried out as dyadic interviews because of the opportunity to interview two KIs from the same setting simultaneously. Four KIs were global or multi-country representatives, eleven provided a national voice, eight represented a Canadian province and two provided insights from the institutional level. KIs self-identified as academics or healthcare professionals (n=17), government representatives or policy makers (n=9), from a not-for-profit organisation (n=5) or other (n=1); seven KIs identified dual roles across sectors. Themes, subthemes and exemplar quotes are described in detail, summarised in table 1, and key findings based on the HPT framework are highlighted in figure 1.
Health policy triangle framework for disease-related malnutrition policies: themes and subthemes
An overview of findings from key informant interviews.
Actors in DRM policy
The HPT framework views actors as organisations, groups or individuals who effect policy.18 This theme captured influential actors in the realm of DRM policy. These actors were actively working in specific settings and countries, or were described as key contributors to DRM policy development and implementation processes. Three subthemes further categorised actors: champions in healthcare, senior leaders in healthcare administration and individuals with lived experience.
Champions in healthcare
Actors that were referred to as ‘champions’ for DRM included healthcare professionals (eg, doctors, dietitians, nurses), and researchers or academics involved in DRM. Embedded healthcare providers were seen as champions of practice change, regardless of their role within the healthcare team. KI-03 (academic and healthcare professional) explained: ‘We [physicians] work together [with dietitians] and we prescribe oral nutritional supplements (ONS) and parental nutrition and ongoing therapy for at home. But normally it’s the dietitian that knows most, and we [physicians] just prescribe it. Some physicians do not know a lot about malnutrition’. Actors’ health backgrounds had evident connections to DRM, yet it was their role as DRM champions that made them essential for DRM policy development and implementation.
KIs commonly described champions in healthcare as individuals who were experts in DRM and trying to initiate DRM policy discussions and implementation efforts. Influential actors often had dual roles (eg, clinician and researcher) and championed practice change beyond what would typically be expected from either position. Roles and titles of champions in healthcare varied across countries and jurisdictions. In some instances, champions leveraged relationships with political actors to raise awareness and support DRM policy action. One KI explained: ‘It takes one or two effective leaders that know how to reach politicians, how to convince them … But if you’re not able to bring it to the leaders, to the politicians, it’s not going to work’ (KI-09, academic and healthcare professional)
One key strategy to advance DRM care, that was identified by KIs, was to engage champions (ie, actors) with the capacity to bring attention and action to DRM policy. In some organisations, this advocacy work was being done through position papers, conferences, meetings and other activities.
You have to keep people engaged. It’s really also a network activity. You need to keep investing in it [DRM policy and advocacy] and make it top priority because these are key opinion leaders with extremely busy schedules. So, you need to be on top of their schedule and you do that by innovating, by adding value through these concepts and inviting them to the conference. (KI-04, policy maker and not-for-profit organisation)
KIs recognised that champions in healthcare hold diverse positions (eg, embedded care provider, researcher, practice leader) and bring essential knowledge and experience that is needed to inform, develop and implement DRM policy.
Senior leaders in healthcare administration
Senior leaders in healthcare administration were identified as essential for organisational level policies targeting DRM. However, these leaders were different from DRM champions as they were often unaware of DRM and its relevance in healthcare (further described in the DRM policy content section). KIs with health policy experience suggested strategies for integrating senior healthcare administration leaders into DRM policy discussions: ‘We’re talking about huge savings if you can keep them [patients] living independently. I’d like to see it as part of the conversation in these provincial, federal […] health authorities because it benefits everybody, it absolutely is cost effective’ (KI-20; academic). Despite their lack of knowledge of the disease, it was evident that senior leaders are needed to progress the development and implementation of DRM policy at the administrative level.
Individuals with lived experience
Individuals with lived experience were identified as actors of utmost relevance for DRM policy. Patients were often discussed as crucial, yet missing, in DRM advocacy efforts. Some KIs noted that certain health conditions, such as diabetes and cardiovascular disease, had greater participation of patient groups in shaping care, whereas patients with other conditions (eg, liver and kidney disease) had less regard for the importance of nutrition. Raising awareness of DRM among patients while understanding their stance and engagement as actors were factors discussed. KI-09 (academic and healthcare professional) noted:
But it’s almost unknown to me that there is a renal patient who is aware that his or her nutritional status is important, or a liver patient. This kind of awareness is not there. So even working with the international patient organizations have honestly not been easy because we are missing the champions.
KIs firmly believed that patient groups need to have a voice in DRM policy discussions because food, as a component of DRM treatment, ought to be understood as a matter of ‘the dignity of the person’ (KI-03, academic and healthcare professional) as well as a human right. Moreover, patient groups would bring diverse voices to DRM policy discussions and provide a lived experience perspective for those who would be most affected by DRM policy.
DRM policy content
The HPT framework broadly considers content as the objectives of a policy.18 This theme included KIs’ views on policy content objectives and areas of focus. KIs provided content examples from clinical practice and general insights pertinent to DRM policy. Three subthemes were identified as vital components of DRM policy content: screening, diagnosis and treatment.
Screening for DRM
KIs involved in DRM research or clinical practice discussed the importance of malnutrition screening as an essential component of care in hospital, especially among older adults. KIs commonly expressed that they were unaware of any consensus (in their respective countries) on how to screen for DRM, yet questions about unintentional weight loss, body mass index and loss of appetite were provided as examples of more widespread DRM indicators used in practice. KIs, primarily from Europe, who were knowledge experts in DRM discussed the GLIM framework10 11 (includes criteria for screening) and its adoption by organisations in some countries.
Diagnosing DRM
DRM policy content needs to address how to formally identify and record a DRM diagnosis. KIs discussed the absence of a formal diagnosis of malnutrition (eg, using an existing International Classifications of Diseases (ICD) code) and how this impacted funding allocation, health professionals’ awareness of DRM and financial supports available to patients in the community. KIs deemed evidence for the diagnosis of malnutrition as key content in DRM policy. Such content could facilitate DRM advocacy and policy implementation in different contexts.
Treating DRM
KIs provided varying levels of detail on DRM treatment based on their experience and area of practice. Treatment-related content was perceived as overlapping with contextual factors and dependent on the setting (eg, hospital, care homes, community) and its priorities. Treatment in care homes is focused on quality of life, whereas the priority in hospital is on recovery, and on prevention in the community.
Regardless of setting and priority, dietitians were viewed as DRM experts, but not all were permitted to provide a medical diagnosis and/or prescribe medical foods (eg, ONS). Often, DRM diagnoses and treatment prescriptions are recognised by health systems with ICD-10 coding by a physician, despite many lacking expertise with DRM. In the community, lack of policy on funding and reimbursement for medical foods (eg, ONS, enteral nutrition) may prevent patients with DRM from accessing prescribed treatments. Access to, and ability to prescribe, medical foods were viewed by KIs as important factors for DRM policy content.
DRM policy context
In the HPT framework, context refers to the systemic factors that influence policy such as social, economic, political, cultural and environmental conditions.18 Questions about policy context focused these factors across three settings: hospitals, care homes and community, as highlighted by the subthemes.
System specifics matter
The context (eg, hospital, care homes or community) is a critical consideration for any DRM policy. Setting-specific factors to consider included where health information is stored (eg, electronic medical record), the healthcare organisation’s capacity for research, the geographical space (eg, country size), the population being served, the workflow and how priorities are established in each context. KI-03 (academic and healthcare professional) explained: ‘In my hospital, the quality of nutrition care is quite high and, because of our research, it’s [quality of nutritional care] quite different from hospital to hospital or from the staff that is working there’.
System-related specific contexts mentioned by KIs were diverse (eg, role and experience of dietitian across care settings, access to home nutrition support, reimbursement process and structure of governing health authority). An enabler for DRM policy implementation in one setting may not be feasible, or be a barrier, in another context. For example, KI-10 (academic and healthcare professional) said: ‘we have one country, one policy. That’s really an enabler’ whereas KI-02 (academic and healthcare professional) described:
We have another problem in [country name]; healthcare is not governed on a national level. There are [number] regions, and they are enormous. All [number] regions have their own way of doing things. There are guidelines and they could follow them, but they can interpret the guidelines in their own way.
It was clear that each setting is unique and complex. Consequently, DRM policy context needs to be well understood to foresee implementation enablers and plan for overcoming potential barriers unique to each setting. Some KIs expressed caution when defining DRM policy context across more than one setting:
I think this is probably in some ways common sense, but the broader it gets, the harder it is to have clear minimum guidelines or standards for everyone. What this looks like in continuing care, you know, it’s probably quite different than what it looks like in community. So that can be tricky. (KI-16, policy maker)
Cost and capacity
KIs unanimously referred to cost savings that arise from proper DRM diagnosis and treatment. KIs discussed the importance of using healthcare data to calculate and demonstrate DRM cost across settings. This contextual factor commonly intersected with the process subtheme on evaluation and research. KIs described the continued need to examine DRM cost to the healthcare system as a contextual enabler to DRM policy. KIs agreed that addressing DRM represented a healthcare cost savings opportunity and that healthcare investment could foster capacity building related to DRM policy. This investment was discussed in relation to increasing the number of healthcare professionals—dietitians, doctors and nurses—who are trained to screen, diagnose and treat DRM in hospitals, care homes and communities. The role of dietitians was commonly emphasised as critical to the success of DRM policy as explained by KI-21 (academic and healthcare professional): ‘I think that we [dietitians] may be one of the only professionals that are not doctors of medicine that could diagnose disease and it is DRM’.
Social determinants of health
KIs commonly mentioned the social determinants of health as other contextual factors to consider. KI-22 (policy maker and healthcare professional) explained:
I do think it’s important to recognize those interrelations between the social determinants of health and malnutrition. Obviously, you’re never going to have a perfect policy … no policy is going to be perfect for everybody. But I do think in developing policies in general, understanding the determinants of health and having that health equity lens is really important.
Within the social determinants of health, food insecurity and the related concepts of access to food and affordability were prominent in the data. Food insecurity was described as lack of financial resources to buy foods needed for recovery from DRM postdischarge from acute care. In the context of community-based settings, food security and affordability were more encompassing concepts that included individuals’ ability to afford sufficient healthy foods for DRM prevention and treatment, as well as medical foods such as ONS prescribed for DRM. KIs discussed the intersection of food insecurity and DRM and believed that even though these two issues could be addressed separately (especially in hospital settings where the focus is on DRM), they would converge in the community. For example, a nutrition professional and policy maker (KI-18) said: ‘It has always seemed really disconcerting […] to do a lot of work screening for malnutrition, identifying and intervening in hospital and then discharging to the very communities where people became malnourished in the first place’. Food insecurity was a contextual factor raised by various KI and acknowledged by all when probed. Consensus on how to address food insecurity in DRM policy was not achieved, yet KIs believed that food insecurity and DRM should be weaved together with other social determinants of health.
DRM policy processes
In the HPT framework, processes refer to initiation, development or formulation, negotiation, communication, implementation and evaluation of policies.18 In this theme, the complexity of DRM policy processes was captured through four subthemes: cross-sectoral and multi-level governance, mandating and other reinforcement strategies, windows of opportunity, and research and evaluation.
Cross-sectoral and multi-level governance
KIs were emphatic that DRM policy should involve multiple disciplines, departments (eg, clinical, nutrition, food services), sectors (eg, social services, primary care) and actors. ‘We also need it to be … that promotion of interdisciplinary, right? It can’t just be an issue for nutrition and food services. It has to be everyone’ (KI-17, healthcare professional and policy maker). KIs believed that stronger engagement across sectors would increase the likelihood for the DRM policy to gain momentum. The importance of mobilising various levels of governance to develop, implement and evaluate DRM policy, was emphasised. Across countries and jurisdictions, there were examples of health policies that were more ‘successful’ when the issue being addressed (eg, fall prevention) was deemed relevant by multiple levels of governance, and the individuals representing them, within governments or organisations.
It would require a neutral platform to bring all of these organizations together and we have done that ourselves … Usually, it’s a third sector organization that provides that neutral platform. And essentially all of this needs to result in maybe two sets of policy actions which might be aimed for. One at the level of clinical policy guidance and the other one at the level of parliamentary policy action. (KI-11, academic and healthcare professional)
Mandating and other reinforcement strategies
KIs expressed support for DRM policy that mandates screening, diagnosis and treatment across settings, especially hospitals and care homes. They described that implementation challenges would persist regardless of policy mandates, secondary to the above mentioned contextual factors. This was exemplified by KIs from countries where national standards for DRM exist, or previously existed but had been removed. KI-10 (academic and healthcare professional) explained:
I think that these quality indicators that we have had for more than 12 years, they have made a difference because it [screening] was mandatory. It was implemented everywhere, 100% implementation. They let it go as of 2019 so I’m really anxious to see what will happen now, whether the hospitals will continue to register [outcome of screening] because it was built into the electronic patient files or whether they will lose attention and forget about it.
Many KIs expressed that implementation strategies such as establishing required organisational practices, moving to an accreditation process, measuring key performance indicators and having a reimbursement model for patients with DRM were required in addition to mandates to foster DRM policy development and implementation. KIs perceived these strategies as effective and more easily achievable than a mandated DRM policy across countries and jurisdictions.
Windows of opportunity
This subtheme captured the timing of DRM policy development and implementation processes. KIs suggested that policy negotiation would be facilitated when other HPT framework factors (ie, context, actors and content) aligned with opportunities to implement DRM policy. For example, KIs suggested that change in hospital meal service, release of new or updated national guidelines, or involvement of individuals with lived experience were windows of opportunity for DRM policy development and implementation.
Evaluation and research
Evaluation of DRM policies was discussed as vital for demonstrating the impact of DRM treatment, particularly for healthcare cost. This subtheme, overlapped with context (cost and capacity), as evaluation of the healthcare costs associated with DRM were thought to be a key driver to policy development and implementation. KIs discussed the importance of having measures in place to demonstrate impact and continuing to raise awareness of DRM among actors (eg, healthcare professionals, policy makers, patient advocates, etc).
Research was seen as key for knowledge generation and dissemination relevant to DRM policy initiatives that can extend to other countries, settings and organisations. KIs discussed research as it related to DRM screening, diagnosis and treatment. Many emphasised the vital role research played in raising awareness of DRM among key policy actors and healthcare professionals. KIs believed that DRM research was an important piece for DRM policy content and context development because it would enable different organisations and settings to prioritise DRM actions. KI-17 (healthcare professional and policy maker) explained:
In my role, we really are thankful for all of the work done by [name of research group] because that has enabled us to have the proof that we need to implement into action various strategies related to malnutrition. We didn’t have to gather all the evidence. The evidence is there.
As such, evaluation was tied to knowledge translation where results from DRM interventions and policies needed to be communicated broadly and effectively to actors across many sectors.
Discussion
Findings from KI interviews suggest that DRM is not well recognised or addressed through health policy in Canada or globally. Key gaps and barriers to DRM policy development and implementation included multi-level governments, jurisdictional priorities and the need for continued advocacy. Social determinants of health, including food insecurity, also emerged as important considerations. These findings align with other work that suggested factors internal and external to the health system have inhibited incorporation of DRM into health policy.26 Building on advances in the field over the past two decades, there is opportunity to leverage the capacity and momentum of DRM initiatives to generate policy that will positively impact health and decrease associated health systems costs.1 This qualitative analysis of KI interviews contributes to the literature describing DRM policies and the value of incorporating implementation initiatives into policy.
KIs acknowledged coalitions, organisational champions and individuals with lived experiences as key actors for DRM policy development and implementation. Organisational leadership (eg, healthcare administrators), interdisciplinary champions (eg, healthcare providers, policy makers, researchers) and nutrition experts (ie, dietitians) are drivers of change and can embody implementation efforts through support, promotion and leadership.15 These actors can be leaders and advocate for change within their local settings to propel DRM policy development and implementation. The conceptual model of champion impact by Shea suggests that commitment, experience and self-efficacy influence champion performance and ultimately impact.27 These champion characteristics align with those mentioned by KIs and suggest that champions are fundamental leaders of change who can support DRM policy and advocacy.
Globally, coalitions of actors have been advocating for improved DRM management. NutritionDay aims to improve DRM awareness and nutrition care of patients.8 This effort is a worldwide scientific programme that operates on a continuous improvement circle and encourages care institutions (hospitals, intensive care units and nursing homes) to register for the initiative, collect data during a 1-day cross-sectional audit and contribute to the growing body of global DRM literature.8 These large-scale efforts to advance DRM would not be possible without key actors including champions, organisational leaders and individuals with lived experience. The results of the current study indicate that further involvement from organisational leaders and individuals with lived experience are needed. DRM policy development and implementation should occur based on setting-specific needs and contexts but can be informed by cross-country coalitions (eg, ONCA9) that provide overarching goals and objectives.
Despite global and national advancements in DRM, gaps exist between current policy and evidence-informed practice. The economic impact of DRM was viewed as a key context consideration for future policy and a lever to gain attention from senior healthcare administrators. In Canada, it is estimated that DRM costs the healthcare system an additional $2 billion per year (pre-COVID-19).1 Patients with DRM remained in hospital 3 days longer, on average, than patients without DRM and incurred approximately $2900 more in hospital costs compared with well nourished patients.1 A complete economic impact analysis is needed to fully appreciate the gravity of this situation post-COVID-19. Appreciation for the problems and implications of DRM is lacking for many organisational leaders who can implement organisational and system-level change. Absence of widespread DRM diagnosis using ICD-codes relates to policy content and actors, as formal diagnoses would draw attention and awareness to DRM among a broader scope of actors (eg, interdisciplinary care team, hospital leadership, etc). Related to HPT context, specifically cost and capacity, the economic impact of poor screening tool sensitivity is one example of the importance of DRM diagnosis by ICD-codes, especially in settings where DRM is prevalent.28 Strategies to combat DRM exist but are not widely implemented given the lack of policy mandate.
Another key group of actors with ability to influence DRM policy are individuals with lived experience. Patients with DRM have lived experience and play a critical role in shaping strategies, advocacy efforts and DRM policy that will impact patient-oriented outcomes, yet their voice is lacking in these initiatives. Similarly, a study that defined DRM as a health policy issue found that the patient plays a key role in policy development.26 A phenomenological study suggested two key approaches to addressing clinical nutrition policy (eg, DRM) including the need for an interdisciplinary approach and a human rights-based approach.26 Nutrition care as a human right has been recognised by an international declaration29 and underpins our findings whereby access to food as treatment for DRM and implications of social determinants of health came through broadly across themes.
Our findings suggested that DRM policy development processes should centre around cross-sectoral and multi-level governance; mandating and other reinforcement strategies for policy; capitalising on windows of opportunity; and using research and evaluation. Current government health policy is focused on prevention of conditions related to overnutrition and chronic diseases whereas healthcare policy addressing disease states, such as DRM, was often viewed as a local facility or organisation responsibility by KIs, rather than the purview or mandate of government.
The need for research to inform policy development and implementation overlapped with all areas of the HPT framework. It was clear that DRM policy processes evolve relative to the HPT actors, content and contexts within the target setting. It is essential for actors invested in DRM policy to understand their setting, context, purpose and evaluative needs to foster targeted and sustainable policy. KIs identified need for policy processes, contexts and content, but provided few tangible examples of policy implementation or evaluation. Key initiatives to standardise the nutrition care process related to DRM (eg, GLIM) in countries that include screening, assessment and diagnosis of DRM10 11 provide examples for others to build on in their efforts to advance DRM policy development and implementation. KIs discussed GLIM as one step towards DRM care consensus, but the need for tangible policy related to nutrition screening, diagnosis and treatment cannot be understated.
Strengths and limitations
The multi-national first-hand perspectives from experts in policy and/or DRM across settings was a strength of this work. We recognise that this is a large and complex topic, and our broad approach of focusing internationally and across multiple care settings introduced further complexity. The decision to take this broad approach was based on the lack of DRM policy within Canada, and the need to learn from the experiences of other countries and settings. The HPT framework provided structure to the interview questions and analysis. A broad range of perspectives were provided which further strengthens our results and their potential utility. Snowball sampling allowed for inclusion of KIs beyond the researcher’s networks. Finally, use of the HPT framework to inform our approach aligns with health policy analysis and is generalisable across jurisdictional settings (from local-level to global-level policy).18
Purposive sampling is a strength and limitation. KIs were selected based on their ability to provide diverse perspectives from a range of expertise and levels of influence on DRM and health policy implementation, including senior leaders in prominent international organisations. Thus, KIs were selected from countries actively working in DRM policy development and/or implementation.
Potential impact
In line with the CANDReaM commitment to the United Nations Decade of Action on Nutrition,14 our findings inform DRM policy development and implementation and are a key step towards advancing DRM policy efforts in Canada and globally. The opportunity identified is the need for DRM policy that involves interdisciplinary care team members, individuals with lived experience and policy makers. The creation of an alliance with involvement from these groups will facilitate DRM policy development. Guidance documents such as the Integrated Nutrition Pathway for Acute Care30 and the CAN/HSO 5066:2021(E) Malnutrition Prevention, Detection and Treatment standard13 are closely related to DRM policy content and exemplify important key steps towards DRM policy development and implementation in Canada. DRM policy context is system-specific and cost analysis is a facilitator for policy advocacy at the health system level. Direction on setting-specific standardised treatment remains a gap to be further explored. A further understanding of the linkage between food security and DRM may provide one avenue for considering the more systemic issues impacting prevention and treatment of DRM. Finally, DRM policy processes are complex and occur at the jurisdictional level (eg, health system, hospital or facility, other). Strategies to support policy implementation13 30 exist but are not widespread. Research and evaluation throughout the policy development and implementation processes in the clinical setting has begun31 and should be spread to community to better understand setting-specific processes.
Conclusion
Gaps and barriers to DRM policy development and implementation exist. There are opportunities and enablers to inform a DRM policy framework. Findings from this study can be used to guide implementation strategies across countries and jurisdictions that incorporate policy as a lever to accelerate practice change. Ultimately, DRM policy will vary and will likely be seen at country-, province-, zone- or site-levels around the world. The landing spot of DRM policy will be informed by actors, content, context and process specifics for each jurisdiction.
Data availability statement
No data are available. Data are transcripts of key informant interviews and contain personally identifying information thus cannot be shared publicly.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and this study was approved by the University of Alberta Research Ethics Board (Pro00127805). All participants provided verbal informed consent.
Acknowledgments
The authors acknowledge Andrea Grantham, Executive Director of the Canadian Nutrition Society and Rupinder Dhaliwal, Programme Manager of the Canadian Malnutrition Task Force for their leadership, commitment and project management support related to the Creating Alliances Nationally to address Disease Related Malnutrition (CANDReaM) initiative. We also wish to acknowledge the NNEdPro Global Institute for Food, Nutrition and Health for support in kinds including article processing charges for publication.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Presented at A preliminary version of this paper will be presented in poster format at the 46th ESPEN Congress on Clinical Nutrition & Metabolism, Milan, Italy, 7–10 September 2024 and will be published in abstract form in a supplement of Clin Nutr ESPEN.
Contributors LG conceptualised the study; LG, KLF, MQ conducted the analysis; all authors reviewed the findings in detail; KLF drafted the manuscript; all authors reviewed and edited the manuscript and have read and agreed to the final version. LG is the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests KLF reports honoraria from Abbott Nutrition; RN and CB-H have no conflicts to declare; MQ owns Quali Q Inc. and provided support for data analysis related to this work; HK and CL report honoraria from Nestle Health Sciences; LG reports honoraria from Baxter, Fresenius Kabi, Takeda; consultancy with Baxter, Fresenius Kabi, Takeda and Abbott Nutrition; research funds from Baxter, Fresenius Kabi and Takeda.
Provenance and peer review Not commissioned; externally peer reviewed.
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