In recent years the public health agenda has focussed on the obesity crisis. Yet malnutrition, which affects some of the most vulnerable people in our society, is often overlooked, writes Ayela Spiro, nutrition science manager at the British Nutrition Foundation.
What do we mean by malnutrition?
Malnutrition has been defined as: a state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue/body form and function, and clinical outcome (Elia, 2003). It can therefore refer to obesity but is used in this article in its commonly recognised term of undernutrition.
It estimated that more than 3 million people in the UK (with around 1 in 10 over the age of 65 years) are either malnourished or at risk of malnutrition (Wilson 2013) , because they do not eat enough for their needs. The number of older people over 75, at highest risk of malnutrition, is projected to almost double in the next 25 years (Rutherford 2012). Older people living in a care home or nursing home or have been admitted to hospital are particularly at risk.
Malnutrition can be difficult to recognise, particularly in patients who are overweight or obese. Signs or symptoms can include loss of appetite, weight loss, loose clothing, jewellery or dentures, reduced physical performance and altered mood. Malnutrition can be identified using a validated screening tool such as the ‘Malnutrition Universal Screening Tool’ (MUST). Recognition of malnutrition amongst health professionals has increased somewhat with NICE guidelines on screening ( see Box 1) and nutrition support (NICE 2006).
Guidance for screening for malnutrition and the risk of malnutrition in hospital and the community (NICE 2006)
• Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training.
• All hospital inpatients on admission and all outpatients at their first clinic appointment should be screened. Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients.
• People in care homes should be screened on admission and when there is clinical concern.
• Screening should take place on initial registration at general practice surgeries and when there is clinical concern. Screening should also be considered at other opportunities (for example, health checks, flu injections).
• Screening should assess body mass index (BMI) and percentage unintentional weight loss and should also consider the time over which nutrient intake has been unintentionally reduced and/or the likelihood of future impaired nutrient intake. The Malnutrition Universal Screening Tool (MUST), for example, may be used to do this.
Attention was also focussed on malnutrition further to the Francis Report into the Mid Staffordshire NHS Foundation Trust, that revealed patients had not been able to drink or eat properly. However too many of us including health and social care professionals, still fail to realise how common malnutrition is or how serious the consequences can be, and it remains under recognised and undertreated (Wilson, 2013). Yet identifying malnutrition (with screening) and effectively managing this condition can improve lives.
Malnutrition adversely effects health outcomes, including physical and psychosocial function (see Table 1). It is associated with poorer recovery, increased infection, admission and re-admission to hospitals and long-term ill health. Good nutrition and hydration can help increase independence, reduce falls, increase wellbeing and reduce pressure sores. (Malnutrition Task Force, 2017). Thus it is imperative that health and social care professionals are able to identify and treat malnutrition effectively.
Table 1: Detrimental effects of malnutrition (adapted from Brotherton et al. 2012)
Effect Consequence Impaired immune response ↓ability to fight infection, ↑ risk of infections and complications, ↑antibiotic use Reduced muscle strength, including reduced respiratory muscle and fatigue ↓mobility, ↑ falls ↑ time recovery from chest infections Impaired wound healing and increased risk of pressure sores ↑ wound related complications e.g. infections and ununited fractures Impaired thermoregulation ↑Predisposition to hypothermia Impaired psychosocial function ↑ inactivity, apathy, depression, ↓ quality of life, ↑self-neglect
Causes of malnutrition
Many interrelated clinical, social and functional factors can influence nutritional status, and these are particularly prevalent in the older population. Older people can have a complex mix of health-care needs accompanied by loss of appetite or difficulty with eating and drinking. Dementia (see box 2), stroke, degenerative neurological conditions, advanced cardio-respiratory disease, cancer and painful arthritis are common conditions, and ones that are often accompanied by loss of appetite or difficulty with eating and drinking (British Geriatrics Society, 2011). For example:
- patients with cancer may have altered taste, nausea and anorexia due to their condition and medical treatment
- patients with stroke or other neurological conditions may have swallowing difficulties or problems with self-feeding
- breathlessness in patients with severe respiratory disease can make eating difficult.
A common feature in palliative care is reduced oral intake, and patients may require additional support to ensure they receive adequate nutrition and hydration. As disease progresses, deterioration in symptoms particularly those involving fatigue, muscular weakness and dysphagia can make eating more difficult.
However, it is also important to recognise that psychosocial issues can have significant effects on dietary intake include poverty, isolation and loneliness, confusion, depression and bereavement (Hickson, 2006).
Nutritional care must ensure that people who are malnourished or at risk of malnutrition are promptly identified through screening, that action is taken to ensure that they receive appropriate and timely nutritional support, and that nutrition care is regularly monitored (NICE, 2006), see box 2. Screening on its own should not be seen as successful nutrition care in practice. Good nutrition ensures that as well as identification of risk, people have access to and/or are supported to consume food that not only meets nutritional, but also cultural and religious needs and preferences (Elia & Wheatley 2014).
Raising awareness to support prevention and early treatment of malnutrition.
Working together within a care home, with GPs, other health professionals, catering staff and relatives.
Identifying malnutrition early through screening and regular assessment.
Delivering personalised care, support and treatment.
Monitoring and evaluating resident weight, improvements and outcome.
Food as first line treatment
Food should be first-line treatment for those at low to medium risk of malnutrition (Pryke & Lopez, 2013). Nutrition support to improve nutritional intake is defined as ‘the modification of food and fluid by fortifying food with protein, carbohydrate and/or fat plus minerals and vitamins; the provision of snacks and/or oral nutrition supplements as extra nutrition to regular meals, changing meal patterns or the provision of dietary advice to patients on how to increase overall nutrition intake by the above.’(NICE, 2006). When patients are unable to consume sufficient nutrition via the oral route, tube feeding may be required. In cases of severe gut dysfunction, intravenous (parenteral) nutrition will be needed.
Oral nutrition supplements (ONS, sometimes referred to as sip feeds) are only one of a spectrum of nutritional support strategies that can be used to tackle malnutrition, although lack of knowledge, historical use and inconsistent messages may promote healthcare staff to regard ONS as the panacea for malnutrition. However, ONS should be largely used after first line dietary measures have been unsuccessful in achieving goals of treatment and should be prescribed appropriately in line with relevant prescription guidelines. ONS have been shown to have clinical benefit, but they may represent a significant waste of resources if they are inappropriately prescribed or poorly monitored (Dominguez Castro et al. 2020). For detailed specialist support consider referral or seeking advice from healthcare professionals such as a dietitian.
More information in this area can be found in Managing Malnutrition with Oral Nutritional Supplements (ONS) – advice for healthcare professionals.
What can help – some practical dietary tips:
- Eating smaller and more often (small meals and snacks including before bedtime): large portions can be off putting.
- Taking advantage of consuming larger meals when appetite is best – breakfast for example can be a good opportunity for increased intake (e.g. cooked breakfast, hot cereals)
- Changing from lower fat to full fat versions of milk, yogurt and cheese, and adding these to foods.
- Increasing energy and protein content by adding dried skimmed milk powder to fortify whole milk (4 tbsp in 1 pint). This fortified milk can be used for sauces, soups, cereal/porridge and in drinks.
- Encouraging higher energy fluids such as milky drinks, fruit smoothies and milkshakes.
- Using high energy snacks between meals to increase energy intake including nuts, dried fruit, cheese or nut butter, houmous and tahini.
- Using olive, nut or rapeseed oil on foods such as potatoes, rice or pasta, chapatis, rotis, noodles and cooked vegetables, and adding coconut milk to curies and stews.
- Trying soft foods if chewing is difficult, like soft potato topped pies, and using gravy or sauces to moisten food.
British Geriatrics Society (2011) Quest for quality an inquiry into the quality of healthcare support for older people in care homes: a call for leadership, partnership and improvement. British Geriatrics Society.
Brotherton A, Simmonds N, Stroud M on behalf of BAPEN Quality Group (2012) Malnutrition Matters. Meeting Quality Standards in Nutritional Care. A Toolkit for Commissioners and Providers in England.
Dominguez Castro P, Reynolds CM, Kennelly S, Clyne B, Bury G, Hanlon D, Murrin C, McCullagh L, Finnigan K, Clarke S, Browne S, Perrotta C, Gibney ER, Corish CA (202). General practitioners’ views on malnutrition management and oral nutritional supplementation prescription in the community: A qualitative study. Clin Nutr ESPEN;36:116-127.
Elia M, (Ed). Screening for malnutrition: a multidisciplinary responsibility. Development and use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for adults. MAG, a Standing Committee of BAPEN. Redditch: BAPEN, 2003.
Elia M, Wheatley C. Nutritional Care and the Patient Voice. Are we being listened to? BAPEN; 2014
Hickson M (2006) Malnutrition and ageing. Postgrad Med J 82(963): 2–8.
Malnutrition Task Force(2017) State of the nation: older people and malnutrition in the UK today. Malnutrition Task Force, London.
NICE (National Institute for Health and Clinical Excellence) (2006) Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition (clinical guidelines 32).
Pryke R, Lopez B (2013) Managing malnutrition in the community: we will all gain from finding and feeding the frail. Br J Gen Pract 63(610): 233–4.
Rutherford T (2012) Population ageing: statistics SN/SG/3228, House of Commons Library Standard
Note: Social and General Statistics [online] Available at www.parliament.uk/briefing-papers/sn03228.pdf
Wilson L (2013) A review and summary of the impact of malnutrition in older people and the reported costs and benefits of interventions. ILC-UK and Malnutrition Task Force, London
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