Undernutrition in the UK

Abstract

There is a nutritional component to most illnesses (whether poor nutrition leads to disease or disease adversely affects nutritional status) and their treatment, often involving all the health care professions. Undernutrition can adversely affect every system of the body such as the muscular system (resulting in fatigue, lethargy and decreased peripheral and respiratory muscle strength), the immune system (predisposing to and delaying recovery from infection) and psycho-social function (causing anxiety, depression and self-neglect). As a consequence, undernutrition consumes a disproportionate amount of health care resources. It is estimated that 70% of undernutrition in the UK goes unrecognised and untreated and that, in the community, 5% of the population have a body mass index (BMI) less than 20 kg/m2. In hospitals this figure rises to 20-25%. It is important to recognise that not all people with low BMI are undernourished; some may be perfectly healthy. There are difficulties in defining undernutrition because the anthropometric measurements used are neither age nor disease specific. Ranges and cut-off points to define normal or ideal have been based on healthy young individuals and are applied to the whole population. However, the three key elements that help define undernutrition or risk of undernutrition are: assessment of chronic protein-energy status, history of weight loss, and underlying risk factors including disease and disabilities. Patients may be malnourished on admission to hospital as a result of a variety of disease-related, social or psychological factors. Mental illnesses such as depression and dementia cause anorexia. Malignancy and acute or chronic physical disease reduce appetite and alter the taste, smell and preferences for different types of food. Infections and malignant disease may also increase nutritional requirements. Neurological and mechanical impairment of swallowing and diseases of the gastrointestinal tract affect nutritional intake. Factors such as social isolation and poverty can play an important role, and disability and immobility can interfere with food purchase and preparation. Taste appreciation also alters with ageing. It is reported that 40% of all patients admitted to hospitals are undernourished, half of them severely so. Nutritional status tends to worsen during hospital stay and is associated with a worse outcome of the disease and prolonged hospital stay. Studies have shown that 40% of hospital food is wasted, which results in patients receiving only 70% of their energy and protein requirements. Because many patients are discharged from hospital in a worse nutritional state than they entered, a further group of undernourished individuals are discharged into the community, setting up a vicious circle. This can largely be prevented or treated with appropriate screening and management. Weight loss often continues in many patients during their hospital stay for many reasons. These include surgical treatments and investigations that impair appetite or the ability to eat (while increasing nutritional requirements) or treatments and procedures that require a period of nil-by-mouth beforehand, which reduces intake. Frustratingly, sometimes a patient may be nil-by-mouth all morning only to have the treatment delayed or postponed to a later date. Often when the patient returns to the ward, no meal has been saved for them (due to lack of communication or lack case, implementing measures such as improved staff training, nutritional screening and assessment, and monitoring, combined with better catering practices will result in most patients' nutritional requirements being met. Fortified meals, between-meal snacks and adequate ward staffing have all been shown to contribute to achieving this goal, which leads to better clinical outcome, less waste, a shorter hospital stay and a more cost-effective service. Recently, a number of schemes and initiatives have been set up to help prevent or combat malnutrition both in hospitals and the community. These include the launch of Better Hospital Food: a new menu for the National Health Service, and the establishment of the Malnutrition Advisory Group, a group of experts convened to raise awareness and understanding of issues of undernutrition. Community initiatives include the establishment of the Neighbourhood Renewal Unit for deprived neighbourhoods, Sure Start - set up to operate local programmes for children and parents living in areas of high poverty, and Healthy Living Centres - set up to run schemes such as luncheon clubs for older people.