Adult malnutrition in the UK is on the rise. NHS experts estimate 3 million people across the country are malnourished or at risk of malnutrition and statistics show hospital admissions for the condition have almost doubled in the past five years.
In last week’s Q&A, our experts discussed the best methods to tackle malnutrition in the UK. Here, we roundup the best bits of their advice.
Panel
Dr Natasha Bye, public and strategic affairs director, Nutricia
Helena Herklots, chief executive, Carers UK
Dr Elizabeth Weekes, consultant dietitian and research lead, Guy’s and St Thomas’ NHS foundation trust
Lesley Carter, programme manager, malnutrition taskforce and project programme manager, Age UK
Dr Alisa Brotherton, honorary secretary, Bapen
Dr Sarah Brice, consultant in geriatric medicine, Imperial College healthcare NHS trust
Wendy-Ling Relph, matron for nutrition and quality, East Kent hospitals university NHS foundation trust and communications officer, Bapen
There needs to be more awareness of adult malnutrition in the UK
Lesley Carter: sometimes people do not recognise the issue. We have found it is not always helpful to use the word malnutrition when raising awareness as older people often do not relate to this. We frame this as having a small appetite or recognising loss of weight when rings, belts and collars get too big. The malnutrition taskforce has also produced some good material on raising awareness of malnutrition in later life.
Dr Alisa Brotherton: we’ve been discussing how to raise the profile of malnutrition across the UK amongst the public recently. We feel now is the perfect time for organisations to join together in designing and delivering one awareness raising campaign – with some very clear messages. There’s lots to learn from the successful campaigns that have been designed and delivered to raise awareness of other conditions such as diabetes, dementia and cancer.
Dr Natasha Bye: it’s important that people realise the extent of malnutrition in the UK. Given one of the earlier comments made, it is appropriate to engage in some myth busting through the media ie – the assumption that if you don’t see lots of people in the street with apparent malnutrition that it can’t exist.
Who is responsible for tackling malnutrition in the UK?
Wendy-Ling Relph: malnutrition is a concern both in hospital and in the community. One in four of admissions into hospital are people who are malnourished. This increases if the patient is older and has a longterm condition. So it’s crucial for GPs to be leading on this with their healthcare teams, for CCCGs to be commissioning appropriate services and for the acute sector to be identifying malnutrition and communicating with services when patients are discharged home. So in other words it’s everyone’s responsibility.
Brotherton: we need everyone in the health and social care system to play their part. If we can align everyone’s efforts to prevent malnutrition where possible, commission for good nutritional care (CCGs), screen early and treat where it effectively where it is found (this is where GPs have a crucial role) and monitor ongoing care then we can be really successful in preventing and reducing malnutrition. Its the same processes needed for screening and treating other conditions. A commitment to act guide on this topic can be found on the Bapen website.
There are more many factors contributing to malnourishment than simply under eating
Dr Sarah Brice: maintaining a good intake of food is not the only issue in malnutrition. The key step (after identifying someone who is losing weight) is to identify why – yes, the intake may be low, but there are other questions – is there an underlying medical problem (infection, cancer, worsening of existing chronic illness), is there depression, cognitive problems such as dementia? Or social issues such as social isolation, poor access to food choices etc. These need to be addressed as well.
Relph: often the area that is concentrated upon by the media is the hospital food. Whilst this is crucial as we need to tempt patients to eat during the acute stages of their illness, there are so many other factors that cause people to be malnourished, as Sarah has highlighted.
There is a large nutritional gap in healthcare. How can this be improved in future?
Brice: nutrition needs a higher profile: there is very little specific nutritional teaching at medical school – and junior doctors don’t perceive nutrition to be anything to do with them. In hospitals, dieticians are very much part of the multidisciplinary team. Nutrition needs a higher profile – and nutritionists need to be building evidence to show that their input improves patient outcomes and in reduces cost to health and social care. We know malnutrition leads to poor outcomes and improved nutrition is good, but the nutritionist role needs to be clarified in that process. It’s not quite all about money, but nearly.
Brotherton: there are few nutritionists working in the NHS, but most health economies do have access to Dietitians. For me, a good starting point would be a national public awareness campaign – as we have had multiple small scale campaigns but with different messages. Once we have identified malnourished individuals sooner, we need to promote self management as a first line step. Once individuals are diagnosed with malnutrition earlier, we will be much better placed to design services to meet needs, including investment of resources where needed.
Dr Natasha Bye: there needs to be a multi-pronged approach. From addressing the basics – such as provision of nutritious meals in institutional settings to addressing social factors such as loneliness, and access to support for individuals and carers. For those people at risk for medical reasons, healthcare professionals need to be able to act early – whether that might be a speedier referral to a dietitian or following NICE guidance and www.malnutritionpathway.org.uk on appropriate use of ONS alongside food.
How can we improve the management of malnutrition in the community to alleviate the burden on hospitals?
Helena Herklots: we need GPs and nurses to screen for risk of malnutrition – and for this to be a standard part of GP consultations and assessments. We also need to support carers to ask the right questions of GPs if they are worried about the person they are looking after – eg to ask the questions “do you think the person I care for is eating enough? Why do you think the person I care for is losing weight? Do you think the person I care for needs to see a dietician?”
Lesley Carter: GPs and practice nurses can raise awareness, recognise and treat. They have a key role as older people visit their GP on average six times per year – so there is plenty of opportunity for them to monitor weight, recognise changes and prevent deterioration in health which may lead to a hospital admission.
What actions are currently in place to improve awareness and tackle malnutrition in the UK?
Dr Sarah Brice: A starting point would be to emphasise that it is not normal for older people to lose weight. This seems to be the perception, in the same way that it is felt that becoming ‘forgetful’ is a part of ‘normal ageing’ – hence older people are left at home with their dementia progressing and no suggestion they should be seen by a doctor, diagnosed and treated. A huge public (and health/care professional) awareness campaign is required as a starting point.
Brotherton: I’d love to see self-screening tested in the community. In the same way that we have self screening promoted for conditions such as breast cancer. It would really raise awareness early, and make effective intervention easier. There’s also a lack of understadning oh how best to treat malnutrition in the community but the community malnutrition pathway is a great resource for community colleagues.
Is it hard to believe that adult malnurition in the UK is so widespread?
Brice: it is hard to believe there is malnutrition with all the high profile articles and warnings about obesity and health. However, it is there, mostly affecting older people and is a very real problem. About 15% of older people living in the community are malnourished. And this has serious health consequences. And yet awareness is low – there are no high profile campaigns as there are for younger overweight people.
Relph: there is not enough of a campaign about this. At a recent NHS England event which Bapen and the National Nurses Nutrition Group were part of, a key point discussed was that the obesity agenda is drowning out the undernourished agenda. Bapen continues to lobby the Department of Health and produce high profile documents to provide national and local strategies to deal with this and finally things are beginning to change. Bapen is part of the malnutrition taskforce and momentum is gaining – hence this debate today.
How to notice undernutrition in the elderly
Relph: some key points for noticing undernutrition are: if someone appears to be losing weight without meaning to. Sometimes this shows itself obviously, but if you haven’t seen them for a while or if the elderly relative hasn’t noticed it themselves, top tips to look out for are maybe their clothes are baggy or dentures no longer fit, belts are done up on a tighter hole, men wear braces rather than belts. Many older people just accept this as part of the normal ageing process and don’t feel it is something worth highlighting to GPs, as mentioned in an earlier post.
Carter: here are some easy tips for noticing if someone is losing or is under weight. Check shirt collars that are looser, thin arms, belts and waistbands looser. Rings falling off of fingers or looking very lose. The dairy council 2013 campaign includes some information materials. See this information on the malnutrition taskforce website.
Brice: older people rarely weigh themselves so you must be perceptive. I saw a lady in an out patient clinic and asked if she’d lost weight…’oh no!’ she said. When I examined her I commented on the nice scarf she was using as a belt for her trousers.. she said ‘that’s because they’ve got so loose in the last few months’… ah ha.
Relph: often those people who are overweight to begin with are missed when their weight is assessed for malnutrition, and are congratulated. This is where education is really needed. It’s so simple – if someone has lost weight, ask if they have deliberately been trying to lose weight. If they haven’t been dieting, then be concerned. Our acute and community health colleagues need more education on this. MUST as a screening tool in hospitals is really useful as it asks this very question, which is why more work is needed to adapt this for community use too.
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