Nutrition - key challenges

Recognising the scale of the problem

Malnutrition and dehydration are common but often go unrecognised and untreated (BAPEN 2010). More than 10 per cent of people aged 65 years and over are malnourished and 70 per cent of undernutrition in the UK is unrecognised (European Nutrition for Health Alliance 2006). Malnutrition and dehydration have been identified as both underlying causes and contributing factors in the deaths of over 800 care home residents between 2005 and 2009 (Mail Online 2011).

In BAPEN’s report of the fourth Nutrition Week Survey undertaken in Spring 2011 malnutrition described as medium and high risk, according to MUST, was found to affect one in four adults on admission to hospitals, more than one in three adults admitted to care homes in the previous six months, and up to one in five adults on admission to Mental Health Units in the UK, and most of those affected were in the high risk category (BAPEN 2012a). The survey also highlighted how the impact on younger age groups as 26 per cent of those aged between 20-29 years admitted to hospital were affected by malnutrition (BAPEN 2012b).   

Human cost

Malnutrition and dehydration greatly increase an individual's vulnerability to illness, clinical complications and death (BAPEN 2012c).  Dehydration is one of the risk factors for falls in older people and is associated with a number of adverse effects including pressure ulcers, faecal impaction and cognitive impairment (Water UK 2005). The clinical effects and consequences of malnutrition are wide ranging (BAPEN 2009). Impaired immune response can impair the ability to fight infection. Reduced muscle strength and fatigue can lead to a reduced ability for self-care and may result in falls. In bed-bound patients this can result in pressure ulcers and blood clots.

NHS Kidney Care, for example, ran a campaign in 2012 to improve inpatient hydration because inadequate hydration is one of the main causes of acute kidney injury (AKI) which affects around one in five people admitted to hospital as an emergency and many elderly patients (NHS Kidney Care 2012). Work done by NHS Kidney Care has found that nearly a third of AKI cases are avoidable.

Financial cost

There is a human cost and there is a financial cost. Disease related malnutrition costs in excess of £13 billion per annum, based on malnutrition prevalence figures and the associated costs of both health and social care" (Malnutritionpathway.co.uk 2012, p 4.). Malnourished inpatients stay in hospital longer (National Institute for Health and Clinical Excellence 2006). A saving of just one per cent of the annual health care cost of malnutrition to the NHS would amount to £130 million annually (NHS Institute for Innovation and Improvement 2010). Hospital food is also being wasted. Ssentif (2011) have revealed that across 200 NHS hospitals and mental health trusts almost eight per cent of all hospital meals go uneaten with a figure of 20 percent or more reported by seven hospital trusts.

Public awareness

A report from Carers UK (2012) based on the experiences of over 2,000 carers says that malnutrition can be a hidden issue. It also makes the point that carers managing someone’s nutritional requirements may be well be aware that problems are developing but do not know where best to seek help, and can feel isolated and guilty that the person they are caring for is becoming malnourished. 

The state of services

Screening and planning for effective nutrition and hydration, coupled with quality food and beverage services and appropriate nutritional support are required in all care settings. This includes considerations around enteral and parenteral as well as oral nutrition (National Institute for Health and Clinical Excellence 2006). The evidence suggests that the reality falls short of what is needed (Age UK 2010; Care Quality Commission 2011). Concerns have also been raised about monitoring and reviewing processes in the administration of parenteral nutrition to ensure effectiveness and safety (National Confidential Enquiry into Patient Outcome and Death 2010).

Identifying factors, targeting actions

Several factors reduce the effectiveness of services (BAPEN 2012c). These include lack of prioritisation of nutritional care, lack of awareness of the multiple impacts of malnutrition and hydration and the lack of trained staff.

Research literature has appreciated the need to move from identifying concerns about nursing performance to targeting actions designed to alleviate contributing factors (University of Birmingham 2011). This includes an understanding of the pressures of the healthcare environment and the demands of productivity and performance.

Nutrition and hydration present a specific set of challenges and require the attention and visible effort given to other patient safety issues (Harm Free Care 2011). Early identification and intervention is key.

Guidance documents and tools have been developed across the UK in response to these challenges. See the Nutrition – improvement actions section in this resource for details of key tools and approaches. See also the listing of tools guidance documents at Core nutritional care resources.


These resources were last accessed on 27 February 2015. Some of them are in PDF format - see how to access PDF files.

Age UK (2010) Still hungry to be heard: the scandal of people in later life becoming malnourished in hospital (PDF 1.43MB), London: Age UK. 
BAPEN (2009) Combating malnutrition: recommendations for action (PDF 50.03KB). Redditch: BAPEN.

BAPEN (2012a) Nutrition screening survey in the UK and Republic of Ireland in 2011 (PDF 4.5MB), Redditch: BAPEN.

BAPEN (2012b) Malnutrition in the community – one quarter of young adults are at risk, BAPEN website.

BAPEN (2012c) Toolkit for Clinical Commissioning Groups and providers in England: Malnutrition matters: meeting quality standards in nutritional care, 2nd.ed. (PDF 4.6MB), Redditch: BAPEN.

Care Quality Commission (2011) Dignity and nutrition inspection programme: National overview, London: CQC.

Carers UK (2012) Carers UK (2012) Malnutrition and caring: the hidden cost for families, London: Carers UK.

European Nutrition for Health Alliance et al (2006) Malnutrition among older people in the community: policy recommendations for change, London: European Nutrition for Health Alliance.

Harm free care (2011). Harm free care website.

Mail Online (2011) How 600 die of thirst in care homes: Damning report exposes the rising number of elderly killed by neglect. Mail Online website.

Malnutritionpathway.co.uk (2012) Managing adult malnutrition in the community, Malnutritionpathway.co.uk website.

National Confidential Enquiry into Patient Outcome and Death (2010) A mixed bag: an enquiry into the care of hospital patients receiving parenteral nutrition, London: NCEPOD.

National Institute for Health and Care Excellence (2006) Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical guideline CG32, London: NICE.
See also: Nutrition support in adults quality standard (QS24).

NHS Institute for Innovation and Improvement (2010) High Impact Actions: Keeping nourished, getting better, NHS Institute website.

NHS Kidney Care (2012) Hydration Matters, NHS Kidney Care website.

Ssentif (2011) Protected mealtimes failing as nine million hospital meals go uneaten (Press release October 2011), Ssentif website.
University of Birmingham Health Services Management Centre (2011) Time to care? Responding to concerns about poor nursing care. (PDF 146.84KB), University of Birmingham HSMC.

Water UK (2005) Wise up on water! Hydration and healthy ageing (PDF 119KB), London: Water UK.