MiOA: Guideline Overview (2023)

MiOA: Guideline Overview (2023)

Guideline Overview 

Guideline Title 
Malnutrition in Older Adults Evidence-Based Nutrition Practice Guideline (2020-23)

Guideline Narrative Overview 


Approximately 25% of older adults (≥65 years of age) are considered malnourished or at risk of malnutrition.1, 2 Malnutrition (undernutrition) is defined as the inadequate intake of protein and/or energy that will negatively impact growth or development and will result in loss of fat stores or muscle mass; and adults at risk for malnutrition are individuals susceptible to malnutrition that can be detected by malnutrition screening. Malnutrition can be starvation related, chronic disease or health condition related, or acute disease or injury related.3 Older adults (≥65 years of age) are at increased risk for malnutrition due to multiple factors, including increased risk for chronic disease and age-related physiological, pathological, sociological, and psychological changes, age-related changes.4, 5 Age is one of the main risk factors for chronic disease, which greatly increases older adults' susceptibility to malnutrition.6 Additional risk factors for malnutrition among the older adult population include frailty, polypharmacy, decline in physical function, cognitive decline, depression, poor appetite, and institutionalization7,  as well as social determinants of health such as social isolation8,  food insecurity,  and more.9 Malnutrition can further increase risk for morbidities and mortality, and decrease quality of life.10

Most older adults live in the community, and approximately 4% live in long-term care (LTC).11, 12 A study conducted in the United Kingdom found that healthcare services, including nutrition care provided outside the hospital can improve accessibility and utilization, while simultaneously decreasing cost.13 There are multiple resources and research studies that provide guidance on the prevention and treatment of malnutrition in acute care settings.14, 18 Evidence-based guidance for nutrition care in LTC and the community is currently lacking. However, it is needed to prevent or treat malnutrition in older adults.     

The objective of this evidence-based nutrition practice guideline (EBNPG) is to provide evidence-based recommendations to identify, prevent or treat protein-energy malnutrition (further referred to as malnutrition) in older adults (mean age of ≥65 years) living in long-term care facilities and in community settings. Improved nutrition status may improve quality of life, prevent decline in physical function, and may decrease the risk of hospitalization and mortality.19, 20 Intended users for this guideline include but are not limited to registered dietitian nutritionists or international equivalents (further referred to as dietitians), nutrition and dietetic technicians, healthcare professionals with different training, such as physicians and nurses, and community health workers who work with older adults and/or their care providers to make shared-decision making to prevent or treat protein-energy malnutrition (undernutrition). When treating malnutrition, healthcare practitioners' primary focus may be improving nutrition status through the use of commonly used nutrition strategies. Prior to delivering nutrition strategies, dietitians should be consulted to ensure safe, efficient, and effective nutrition care.21

Topics addressed in this guideline include:

  • Nutrition Assessment  
    • Mini-Nutritional Assessment
    • Subjective Global Assessment
    • Patient-General Subjective Global Assessment
  • Oral Nutrition Supplements
  • Dietitian Effectiveness
  • Food Fortification
  • Home Delivered Meals and Congregate Meals

The number of supporting documents for these topics is:

  • Recommendations: 12
  • Conclusion Statements: 51
  • Evidence Summaries: 45
  • Article Worksheets: 18

To learn about the Academy's systematic review methodology and guideline development process, visit the Policy and Procedures section of the Evidence Analysis Library (EAL).


Expand the section titled Project Team and Disclosures to see the list of individuals who developed this guideline.


Academy guidelines are revisited every five years. An expert workgroup will be convened by the Workgroup Selection subcommittee of the Council of Research (COR) to determine the need for new and revised recommendations based on the available science. The process includes:

  • Conduct a scoping review to identify new research published since the previous searches were completed. Updated inclusion/exclusion criteria and search terms may be warranted. 
  • Review to determine if the update will include modifications to recommendations and compare them to the earlier version of the guidelines, or development of new recommendations.


  1. Dent E, Wright ORL, Woo J, Hoogendijk EO. Malnutrition in older adults. The Lancet. 2023;401(10380):951-966. 
  2. Guigoz Y. The Mini Nutritional Assessment (MNA) review of the literature--What does it tell us? J Nutr Health Aging. 2006;10(6):466-485; discussion 485-467. 
  3. Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT):  Dietetics Language for Nutrition Care. MALNUTRITION (UNDERNUTRITION) Web site. Accessed. 
  4. Landi F, Calvani R, Tosato M, et al. Anorexia of Aging: Risk Factors, Consequences, and Potential Treatments. Nutrients. 2016;8(2):69.  
  5. Evans C. Malnutrition in the elderly: a multifactorial failure to thrive. Permanente J. 2005;9(3):38-41. 
  6. Hickson M. Malnutrition and ageing. Postgrad Med J. 2006;82(963):2-8.  
  7. Fávaro-Moreira NC, Krausch-Hofmann S, Matthys C, et al. Risk Factors for Malnutrition in Older Adults: A Systematic Review of the Literature Based on Longitudinal Data. Adv Nutr. 2016;7(3):507-522.  
  8. Boulos C, Salameh P, Barberger-Gateau P. Social isolation and risk for malnutrition among older people. Geriatr Gerontol Int. 2016;17(2):286-294. 
  9. Grammatikopoulou MG, Gkiouras K, Theodoridis X, et al. Food insecurity increases the risk of malnutrition among community-dwelling older adults. Maturitas. 2019;119:8-13. 
  10. Mangels AR. CE: Malnutrition in Older Adults. Am J Nurs. 2018;118(3):34-41.  
  11. Crichton M, Craven D, Mackay H, Marx W, de van der Schueren M, Marshall S. A systematic review, meta-analysis and meta-regression of the prevalence of protein-energy malnutrition: associations with geographical region and sex. Age Ageing. 2019;48(1):38-48. 
  12. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2016: Key Indicators of Well-Being. U.S. Government Printing Office, Published 2016. Accessed May 22, 2020. 
  13. Winpenny E, Miani C, Pitchforth E, et al. Health Services and Delivery Research, No. 4. 15. In: NIHR Journals Library, ed. Outpatient services and primary care: scoping review, substudies and international comparisons. Southampton (UK)2016.  
  14. Ostrowska J, Sulz I, Tarantino S, Hiesmayr M, Szostak-Wegierek D. Hospital Malnutrition, Nutritional Risk Factors, and Elements of Nutritional Care in Europe: Comparison of Polish Results with All European Countries Participating in the nDay Survey. Nutrients. 2021;13(1).  
  15. Schuetz P, Seres D, Lobo DN, Gomes F, Kaegi-Braun N, Stanga Z. Management of disease-related malnutrition for patients being treated in hospital. Lancet. 2021;398(10314):1927-1938.  
  16. Kaegi-Braun N, Mueller M, Schuetz P, Mueller B, Kutz A. Evaluation of Nutritional Support and In-Hospital Mortality in Patients With Malnutrition. JAMA Network Open. 2021;4(1):e2033433. 
  17. Bellanti F, Lo Buglio A, Quiete S, Vendemiale G. Malnutrition in Hospitalized Old Patients: Screening and Diagnosis, Clinical Outcomes, and Management. Nutrients. 2022;14(4).  
  18. Vanderwee K, Clays E, Bocquaert I, et al. Malnutrition and nutritional care practices in hospital wards for older people. J Adv Nurs. 2011;67(4):736-746. 
  19. Marshall S, Bauer J, Isenring E. The consequences of malnutrition following discharge from rehabilitation to the community: a systematic review of current evidence in older adults. J Hum Nutr Diet. 2014;27(2):133-141. 
  20. Chan HCN, Fei X, Leung ELY, Langston K, Marshall S, van der Meij BS. Post-discharge consequences of protein-energy malnutrition, sarcopenia, and frailty in older adults admitted to rehabilitation: A systematic review. Clin Nutr ESPEN. 2023;54:382-397. 
  21. Roberts S, Collins P, Rattray M. Identifying and Managing Malnutrition, Frailty and Sarcopenia in the Community: A Narrative Review. Nutrients. 2021;13(7).
Proceed to Guideline Scope Return to MiOA Home