Post-discharge malnutrition interventions through the lens of behavior change theory: A scoping review

Malnutrition commonly coexists alongside a medical diagnosis in hospitalized people and may not fully resolve prior to discharge. Post-discharge interventions aim to increase nutrient consumption to improve downstream outcomes, yet strategies that effectively support this behaviour change are not clearly delineated in the literature. This scoping review aimed to characterize the recent literature on post-discharge malnutrition interventions through the lens of the Capability, Opportunity and Motivation system of behaviour (COM-B) to demonstrate the relevance of behavior change theory to post-discharge intervention design and identify opportunities to support future success.

The review was conducted in accordance with published methodology for scoping reviews. Studies published from 2015 to 2024 describing post-discharge nutrition care of adults with malnutrition or nutrition risk were included, excluding those with >50% of participants discharged to residential care facilities, having diagnosed eating disorders, or undergoing cancer-directed therapy after discharge. References reporting outcomes from the same trial were merged and considered as one study. Intended participant behaviors were identified and strategies used to support these participant behaviors were classified according to the COM-B model. Trial outcomes were tabulated and visualized.

31 eligible manuscripts were identified, describing 21 unique studies. Participants were predominantly asked to either 1) implement a nutrition plan or advice (9/21) or 2) consume specific products including oral nutritional supplements, snacks, or meals (9/21). Primary strategies used to support these behaviors included provision of nutrition counseling/education (14/21), products (12/21), and educational materials (10/21). When aligned with the COM-B system, support strategies mainly addressed psychological capability (18/21), physical opportunity (12/21) and reflective motivation (12/21), while none targeted physical capability, social opportunity, or automatic motivation. Positive effects on primary outcomes selected a priori were reported in only 5/21 studies. Participant achievement of desired behavior was never assessed or reported as an outcome; rather, it was variably described as adherence mainly in studies asking participants to consume specific products.

Post-discharge interventions rely on patients to change eating behaviour to achieve nutrient requirements, yet few post-discharge trials have been designed as behavioral interventions. Novel post-discharge strategies beyond education, nutrition counseling or supplement provision are needed to address barriers to behaviour change for people with malnutrition, informed by behaviour change theories. In addition, clearer definition, systematic measurement and reporting of participant eating behavior in future trials will increase our collective understanding of which strategies work for whom, advancing personalized nutrition care practice to improve patient outcomes.