Malnutrition in the UK: the importance
of nutritional screening
Christine Russell
Chair BAPEN’s Nutrition Screening Week
www.bapen.org.uk
Registered Charity No: 1023927
Overview
• Understand the meaning of ‘malnutrition’
• Appreciate the prevalence of malnutrition in UK
• Understand the causes and consequences of the
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problem
Understand the difference between screening and
assessment.
Use of the ‘Malnutrition Universal Screening Tool’
(‘MUST’) and e-learning module
Importance of care planning
BAPEN www.bapen.org.uk
Multi-disciplinary charity committed to raising awareness of
malnutrition and its impact on health & social care budgets
and resources, personal experiences and health outcomes
in order to improve nutritional care
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Practical screening tool – ‘MUST’
Financial statistics- health economics /cost of malnutrition in UK
Audit data – British Artificial Nutrition Survey (BANS)
Nutrition Screening Surveys – hospital, care, mental health, sheltered housing
Policy recommendations & action working with Governments & statutory
agencies
‘Patient’ & consumer group opinions
Campaigning & communicating
What is malnutrition ?
• Literally means “bad” nutrition which can
mean over nutrition or under nutrition
• No internationally agreed criteria to define
malnutrition
Proposed definition of malnutrition
“ A state of nutrition in which a deficiency or
excess (or imbalance) of energy, protein and
other nutrients causes measurable adverse
effects on tissue/body structure and
function and on clinical outcome” (Elia/ MAG
2003)
Here we will focus on under-nutrition
Causes of Malnutrition
Multi-factorial!
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Clinical – associated with disease leading to problems such as
nausea and vomiting, pain, malabsorption, infections, difficulty
eating and swallowing, confusion, medication…
Ageing process -important changes to the body occur
Lifestyle –access to shops, finances, cultural, living conditions,
bereavement, depression, cooking ability and knowledge
Effects of under-nutrition on organ function
Ventilation - loss of
muscle & hypoxic
responses
Psychology –
depression & apathy
Immunity – Increased risk
of infection
liver fatty change,
functional decline
necrosis, fibrosis
Decreased cardiac output
Renal function - loss of
ability to excrete
Na & H2O
Impaired wound
healing
Hypothermia
Impaired gut
integrity and
immunity
Anorexia
Loss of strength
Consequences of malnutrition
• Increased risk of admission into hospital
• Increased complications and dependency
• Increased length of stay in hospital
• Increased cost of care
• Increased mortality
• More likely to be discharged into care home
• Increased risk of being re-admitted post discharge from hospital
The Cost of Obesity & ‘malnutrition’
Costs to NHS in 2007 ~£4.2 billion/year
Costs of ‘malnutrition’ in 2007 ≥£13 billion/ year
(Costs exclude the consequences of
obesity or under-nutrition)
Groups at risk
• Individuals with acute or chronic conditions
• Those recently discharged from hospital
• Older people
Malnutrition can be exacerbated by:
• Poverty
• Social isolation
• Substance misuse
• Religious / cultural beliefs / practices if not
adequately considered when in care
Percentage of people aged 65+ at
medium/high risk of malnutrition
North England
19.4%
Wales 11%
South England
Central England
12.3%
11.3%
Source: further analysis of
1998 NDNS Survey data
• BAPEN’s National Nutrition Screening Weeks:
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September 2007, July 2008, January 2010 and April
2011
To establish current prevalence /risk of malnutrition
on admission to hospital, care homes and mental
health units in UK
General questionnaire re nutritional care
Data collection forms based on ‘MUST’ criteria
• 28-34% patients admitted to hospital were at
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risk – most patients being at high risk
18-20% patients admitted to mental health
units
30- 40% residents admitted to care homes in
previous 6 mths were at risk
Prevalence in other care settings
• ≥10 -20% in outpatients- high in patients with
COPD
• 12-14% in sheltered housing
• ~25% in patients receiving care at home
Need to identify the problem as
early as possible
• Much malnutrition originates in the community
• Hospitals provide an ideal opportunity to Identify the
problem
• If unchecked the problem can spiral and get
progressively worse
The Malnutrition Carousel
28-34% of patients
admitted to hospital are at
risk of malnutrition
Hospital
Home
More GP visits
Longer stay
More hospital
admissions
More support postdischarge
More likely to be
discharged to Care Homes
Up to 70% of patients
discharged from hospital
weigh less than on admission
Why screen for malnutrition?
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Malnutrition is not always visible, is more common than you
think and costs health and social care ≥£13b/year
• At any one time, more than 3 million adults in UK are at risk
• 93% live in the community & 2% are in hospital where ~1 in 3
are at risk on admission
• Older people and those with chronic conditions are
particularly at risk
• Help people stay independent and well in their own home as
long as possible & reduce the need for admission into hospital
Why screen for malnutrition?
• Effective management of malnutrition reduces the
burden on health & care resources
• Regular screening is the only way that malnourished
individuals can be identified and appropriate action
taken
• Recommended / required by various bodies e.g NICE,
NHSQIS, Council of Europe, Care Quality Commission,
Nutrition Action Plan
NICE recommendations- Who to screen & when?
• In Hospital – on
admission, repeat weekly.
Outpatients: if clinical
concern
• In Care – on admission
& if clinical concern
• In the Community –
on registering with a GP
& at other times e.g
health checks, flu jabs
What is clinical concern?
Unintentional weight loss, fragile skin, poor wound
healing, apathy, wasted muscles, poor appetite,
impaired swallowing, altered bowel habit, loose
fitting clothes or prolonged inter-current illness. (NICE
2006)
What is screening and how can we
do it?
Nutritional screening
“Rapid, simple, general procedure done at first
contact with subject to detect risk of malnutrition,
done by nurses, doctors or other care workers”
(Elia/ MAG 2003)
Complementary to and part of nurse assessment
Nutritional assessment
“Detailed, more specific in depth evaluation of
subject’s nutritional status, done by those with
nutritional expertise” (Elia/ MAG 2003)
‘Malnutrition Universal Screening Tool’
(‘MUST’)
A simple 5 step validated tool for use by all care
workers in all care settings:
• Step 1-height and weight to obtain BMI
• Step 2- recent unintentional weight loss
• Step 3- effect of acute disease
• Step 4- overall score / category of risk
• Step 5- management guidelines
‘Malnutrition Universal Screening
Tool’ (‘MUST’)
The old ones are the best
“It is not for the sake of
piling up miscellaneous
information or curious
facts, but for the sake of
saving life and
increasing health and
comfort”
F Nightingale 1859
Care plan
• Set aims and objectives
• Treat underlying conditions
• Improve nutritional intake in line with local
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policy
Monitor and review
Reassess subjects at nutritional risk as they
move through care settings
Include nutritional information in discharge
communications
Implementation of nutritional
screening
• Education and training of those involved
• Audit of practice
• Resources available:
– Local workshops/lectures/workbooks
– E-learning
‘MUST’ e-learning
Developed in
partnership with
NHS Greater
Glasgow and
Clyde
‘MUST’ e-learning
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For healthcare staff working in hospital
– Causes and consequences malnutrition
– How to screen using ‘MUST’
– Online assessment
– Optional reporting system
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Hosted on secure server
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Accessible via internet from work or home
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SCORM compliant version in development
‘MUST’ e-learning
• Community module
now available
• Healthcare staff
working in
– Primary Care
– Care Homes
‘MUST’ e-learning
Link to Hospital module:
https://secure.digitalroutes.co.uk/bapen