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Key challenges

Malnutrition and dehydration are common but often go unrecognised and untreated (1). 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 (2). 

Malnutrition and dehydration were identified as underlying causes and contributing factors in the deaths of more than 650 care home residents between 2005 and 2009 (2).

Human cost

Malnutrition and dehydration greatly increase an individual's vulnerability to illness, clinical complications and death (3). Dehydration is one of the risk factors for falls in older people and is associated with pressure ulcers, faecal impaction and cognitive impairment.The clinical effects and consequences of malnutrition are wide ranging. Impaired immune response can weakenthe ability to fight infection. Reduced muscle strength and fatigue can impede self-care and may result in falls. In bed-bound patients this can result in pressure ulcers and blood clots.

Financial cost

According to Malnutrition Pathway (4), disease related malnutrition costs the NHS  more than £13 billion per year based on malnutrition figures and the associated costs of both health and social care (4). A saving of just one per cent of the annual health care cost of malnutrition to the NHS would amount to £130 million annually (4).

Public awareness

A report from Carers UK (7) based on the experiences of more than 2,000 carers says that malnutrition can be a hidden issue. Carers may be unaware of where best to seek help, and can feel isolated and guilty that the person they are caring for is becoming malnourished, according to the report.

The state of services

Screening and planning for effective nutrition and hydration, coupled with quality food and beverage services and appropriate nutritional support are needed in all care settings. This includes considerations around enteral and parenteral as well as oral nutrition (2). Evidence collected by Age UK suggests that the reality falls short of what is needed (1; 8). Concerns have also been raised about monitoring and reviewing processes in the administration of parenteral nutrition to ensure effectiveness and safety (9).

Identifying factors, targeting actions

Several factors reduce the effectiveness of services (3). 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 from the University of Birmingham has noted the need to move from identifying concerns about nursing performance to targeting actions designed to alleviate contributing factors. 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 need the attention and visible effort given to other patient safety issues (12). Early identification and intervention are essential.

Guidance documents and tools have been developed across the UK in response to these challenges. See the Nutrition – improvement actions page in this Clinical Topic for tools and approaches. 


  1. 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
  2. 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.
  3. 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.
  4. (2012) Managing adult malnutrition in the community, website.
  5. 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.
  6. NHS Institute for Innovation and Improvement (2010) High Impact Actions: Keeping nourished, getting better, NHS Institute website.
  7. Carers UK (2012) Carers UK (2012) Malnutrition and caring: the hidden cost for families, London: Carers UK.
  8. Care Quality Commission (2011) Dignity and nutrition inspection programme: National overview, London: CQC.
  9. 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.
  10. Age UK (2010) Still hungry to be heard: the scandal of people in later life becoming malnourished in hospital, London: Age UK
  11. 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.
  12. Harm free care (2011). Harm free care website.
  13. See also: National Institute for Health and Care Excellence. Nutrition support in adults quality standard (QS24), London: NICE.