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Individuals who are malnourished or at risk of malnutrition are susceptible to a range of adverse clinical consequences, including an increased risk of fall,1,2 impaired recovery from illness and surgery,3 higher mortality,3 reduced muscle strength and frailty,4,5 plus impaired immune response, wound healing and psycho-social function.3 This not only has a significant impact on their quality of life, but also puts a considerable strain on health resources.
So why as a society do we tend to ignore it, often wrongly considering weight loss and frailty to be inevitable part of ageing or of a disease process?
Prevalence
At any point in time more than three million people in this country are malnourished or at-risk of malnutrition, it is estimated that almost half of these are aged over 65 years6 and that most (~93%) reside in the community.7
Malnutrition is estimated to affect:
Who is most at risk of malnutrition?
Malnutrition and unintentional weight loss in the older population and amongst other at risk groups can contribute to a progressive decline in health, reduced physical and cognitive functional status, increased utilisation of health care services, premature institutionalisation and increased mortality.10 In care homes disease-related malnutrition predisposes residents to infections, pressure ulcers and a greater number of days in bed.11 Effectively managing malnutrition is integral to the successful treatment of frailty – a key focus for the NHS, with the routine identification of frailty in patients who are 65 and over now being part of the GP contract.
Groups most at risk of malnutrition include those with:
- Frailty3,12: immobility, old age, depression, recent discharge from hospital
- Multi-morbidity or chronic disease3,7 (consider acute episodes): chronic obstructive pulmonary disease (COPD), cancer, gastrointestinal disease, renal or liver disease and inflammatory conditions such as rheumatoid arthritis, inflammatory bowel disease
- Progressive neurological disease:7 dementia, Parkinson’s disease, motor neurone disease (MND)
- Acute illness:7 where adequate food is not being consumed for more than five days (more commonly seen in a hospital than a community setting)
- Social issues:7 poor support, housebound, difficulty obtaining or preparing food
- Rehabilitation: after stroke,7 injury,3 cancer treatment3
- End of life/palliative care.13,14
Screening and management
NICE recommends that screening for malnutrition should be undertaken across all health and social care settings and that a validated tool such as the Malnutrition Universal Screening Tool (MUST’)15 may be used to do this.16 Screening can be undertaken by any trained care provider and is easily integrated into existing pathways of care.
After screening, appropriate action must then be taken to manage those patients found to be malnourished or at risk of malnutrition. The ‘Guide to Managing Adult Malnutrition in the Community’17 (www.malnutritionpathway.co.uk – free download) is a practical guide, developed by a multi-professional expert panel and endorsed by the Royal College of General Practitioners, to support healthcare professionals in identifying and managing malnutrition. With over 90% of malnutrition in the UK existing in the community, the primary care multidisciplinary team have a fundamentally important role in managing this problem.
The cost of not treating is greater than the cost of treating
The cost of malnutrition in the UK alone is in excess of £23 billion per annum, based on malnutrition prevalence figures and the associated costs of both health and social care.18 The estimated annual cost of healthcare for a malnourished patient is £5,763 (based on the point prevalence of malnutrition and annual expenditure on malnutrition) and £1,645 for social care, compared to the costs for non-malnourished patients of £1,715 and £440, respectively.18 NICE have shown substantial cost savings can result from identifying and treating malnutrition: implementation of the Clinical Guideline 32: Nutrition Support for Adults16 and supporting Quality Standard 24.19 These cost savings come largely from reducing healthcare resource use, such as GP visits, hospital readmissions and length of hospital stay.
Should we be prescribing nutritional supplements?
There continues to be much debate in relation to the prescription of food for special medical purposes with many CCGs now restricting prescriptions, often without examining long term patient outcomes. However, systematic review evidence, including work by NICE (A-grade evidence), have demonstrated that oral nutritional supplements (ONS) are clinically and cost effective in managing malnutrition, particularly amongst those with a low BMI (<20kg/m2).16,20–22
Whilst there is some evidence for managing malnutrition with dietary advice alone, data on clinical outcomes and cost effectiveness are limited.23 There is often a misconception that ONS are a substitute for food, however they should be used in addition to the normal diet when diet alone is insufficient to meet daily nutritional requirements and not as a food replacement, with the exception of cases where food intake is not feasible or is contraindicated. Evidence shows that ONS do not reduce intake of normal food over a 12-week period.24,25
The clinical benefits of ONS include reductions in complications (eg. pressure ulcers, poor wound healing, infections)21,26 and improvements in weight, as well as functional benefits such as improved hand grip strength and quality of life.16, 20, 21, 25, 27, 28
Research carried out in Southampton amongst 104 malnourished care homes residents (those at medium and high risk of malnutrition) indicated that the use of ONS can improve quality of life and nutritional intake more effectively than dietary advice alone. It also suggested that the use of ONS in care homes are cost effective relative to dietary advice.25,29
It is important that the prescribing of ONS forms part of a pathway of care; goals should be set, the intervention monitored and stopped when appropriate and follow up in place to review progress. Consideration also needs to be given to the type of ONS which might be relevant for the patient€”for example, a high protein ONS may be more suitable for individuals with COPD, wounds, post-operatively and for older people with frailty, whilst fibre-containing ONS may be more useful for those with GI disturbances.
Conclusion
The growing older population are increasingly utilising healthcare resources; the costs associated with malnutrition in this group will undoubtedly add to the challenges of managing and funding healthcare resources. Healthcare teams therefore need to address the role of malnutrition in disease management and consider the following:
- Think about nutritional care at every patient contact and avoid accepting weight loss as an inevitable part of ageing or the disease process – we have strategies in place to assess patient’s BMI in order to tackle obesity; we need to have similar strategies to tackle malnutrition (where patients have a BMI less than 20kg/m2 and/or have experienced unplanned weight loss).
- Incorporate nutrition screening and management into local care pathways – ensuring all professionals are encouraged to take responsibility in this area. Pathways of care are available in the Managing Adult Malnutrition in the Community’ guidance17 (www.malnutritionpathway.co.uk) for example, includes two pathways -”the first looks at managing malnutrition according to risk category using the ‘Malnutrition Universal Screening Tool’15 (‘MUST’) and the second advises on the appropriate use of oral nutritional supplements (ONS) (what, when and for how long) for high risk patients. A pathway is also available on the site for patients with COPD. Such care pathways could easily be adapted and incorporated into existing local care pathways for a number of disease processes.
- Work more closely with dietitians across both hospital and community care settings, ensuring that where malnourished patients are discharged from hospital into the community there is transfer of appropriate clinical information to assist community professionals to further optimise nutritional care.
- Recognise the medium-to-longer term benefits to patients and the wider healthcare system that can be achieved as a result of implementing effective nutritional care pathways.
Dr Trevor Smith, Consultant Gastroenterologist at University Hospital Southampton NHS Foundation Trust and President Elect of the British Association for Parenteral and Enteral Nutrition (BAPEN)
References
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3. Stratton RJ, et al. Disease-related malnutrition: an evidence-based approach to treatment. Oxford: CABI publishing; 2003
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6. BAPEN. Introduction to Malnutrition. http://www.bapen.org.uk/about-malnutrition/introduction-to-malnutrition?showall=&start=4 Accessed 15 Aug 2018
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