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 have launched a campaign 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 survey carried out by the Patients Association (2011) also reveals a lack of awareness amongst patients and carers regarding risk of and prevention of malnutrition and where to seek advice. The survey report calls for a proactive approach to malnutrition prevention in the community and as part of the public health service.

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).

Guidance documents and tools have been developed across the UK in reponse to these challenges. These are described at Core nutritional care resources.

References

These resources were last accessed on 7 December 2012. 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, 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.

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 Clinical Excellence (2006) Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical guideline CG32, London: NICE.

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.

Patients Association (2011) Malnutrition in the community and hospital setting (PDF 412.79KB), Harrow, Middlesex: Patients Association.

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.

Further resources

British Dietetic Association (2011) Mind the hunger gap campaign
This campaign was launched by the British Dietetic Association in November 2011 calling on all dietitians in the UK to highlight concerns around malnutrition in older people living in the community. According to the campaign website, a conservative estimate is that around one million older people in the UK are eating less than one square meal a day and the figure does not include older people in a hospital or care setting. The campaign tools include information for the public on recognising malnutrition and a leaflet for adults who have poor appetite or have lost weight, 'Eating better, feeling better’.

Managing adult malnutrition in the community (2012)
This website provides practical support to general practitioners and healthcare professionals in the community to identify and manage individuals at risk of disease related malnutrition. It includes a pathway which supports the appropriate use of oral nutritional supplements. The contents of this document have been written and agreed by a multi-professional consensus panel with expertise and an interest in malnutrition and the resource is supported by a range of organisations including the Royal College of Nursing.

NHS Kidney Care (2012) Hydration Matters
NHS Kidney Care have launched a campaign to improve inpatient hydration and to encourage staff in hospitals and nursing homes to better monitor and manage inpatients’ fluid status. Inadequate hydration is one of the main causes of acute kidney injury (AKI) and other avoidable healthcare complications. The campaign brings together information about acute kidney injury and risk factors for this as well as resources to support improved hydration.