APPENDIX 18
Memorandum by The Malnutrition Advisory
Group (PH 33)
CONTENTS
1. Executive Summary
2. Introduction
3. The Malnutrition Advisory Group
4. Undernutrition: A National Health Problem
5. Causes of Undernutrition
6. Consequences of Undernutrition
7. Underrecognition and Undertreatment
8. Treating Undernutrition
9. Costs to the NHS
10. Why does Undernutrition?
11. Malnutrition and Health Policy
12. Recommendations
EXECUTIVE SUMMARY
1.1 Undernutrition: a UK public health problem
Disease and illness are the major causes of
undernutrition in the UK. However, poverty, social isolation and
deprivation all exacerbate the incidence of undernutrition. In
the community around one in 10 people who are suffering from chronic
diseases such as cancer or are recovering from surgery are undernourished.
Undernutrition appears to be more common in lower social classes.
The majority of undernutrition exists in the
community, but the incidence is even greater in nursing homes
and hospitals. Surveys have found that up to 40 per cent of adults,
15 to 30 per cent of children and up to 60 per cent of older people
are malnourished on admission to hospital. Whilst in hospital
they lose even more weight and they often return to the community
more malnourished than when they were admitted. This sets up the
malnutrition carousel between hospitals and community.
Undernutrition is under-recognised and under-treated
in hospital inpatient and outpatient departments, nursing homes
and in free-living patients.
Malnutrition increases the number of GP consultations
and the length of hospital stay with spiralling costs to the NHS.
However, early detection and treatment can improve disease outcome
and well-being with no overall additional costs.
1.2 BAPEN—MAG
The British Association for Parental and Enteral
Nutrition (BAPEN) is a multidisciplinary association and registered
charity which was formed in 1992 as a result of recommendations
made in the King's Fund Report "A Positive Approach to Nutrition
as Treatment". The Association's aim is to improve the nutritional
treatment of the sick who are, or are likely to become, malnourished
as a consequence of their illness.
BAPEN's concern over the general lack of awareness
and inadequate management of disease-related malnutrition in hospital
and the community has led to the formation of the Malnutrition
Advisory Group (MAG). The MAG is a working group of BAPEN, tasked
to raise awareness of the problems of community-based malnutrition,
to work actively with government agencies and to emphasise that
malnutrition is a major UK public health problem which is not
restricted to the developing world.
1.3 Everybody's concern but no-one's responsibility
Policy to reduce the prevalence of malnutrition
in the UK is under-developed and fragmented. There is the danger
that malnutrition may become everybody's concern but no-one's
responsibility. Therefore there is an immediate need to establish
an integrated policy that encompasses:
1. clinical nutrition and public health medicine;
2. primary, secondary and tertiary care;
3. undernutrition and overnutrition; and
The MAG recommends that the following policy
initiatives are implemented:
— nutritional considerations should
play a role in all aspects of the clinical governance framework
and public health policy;
— opportunities should be taken to
screen for malnutrition in primary care and on admission to hospital;
— patients should receive appropriate
nutritional intervention where malnutrition is detected; and
— robust indicators need to be established
to ensure policy is effectively implemented.
The MAG would like to see all the above elements
included in relevant policy initiatives where appropriate, eg
health improvement programmes.
1.4 Co-ordination of policy
The MAG recommends that the following steps
are taken to co-ordinate policy:
— the Minister of Public Health to
be given responsibility to co-ordinate policy to reduce the prevalence
of malnutrition in the UK;
— a senior policy officer to be appointed
to assist the minister and co-ordinate policy across the Department
of Health;
— local bodies such as primary care
groups and health authorities should monitor the implementation
of policy at a local level;
— agencies such as the Audit Commission,
the Commission for Health Improvement and community health councils
should scrutinise progress; and
— robust indicators should measure
the policy outcomes to help monitor action.
1.5 Education and training of health professionals
The MAG recommends that the training and education
of health professionals to detect, treat and manage malnutrition
is also very important in the fight against malnutrition.
1.6 Conclusions
— Treatable malnutrition has no place
in a modern and dependable health service in the 21st century.
— Malnutrition is often unrecognised
and untreated. Unless action is taken the malnutrition carousel
will continue to revolve between hospital and community.
— Because malnutrition crosses medical
disciplines there is a danger that malnutrition will be everybody's
concern and no-one's responsibility.
— The Government's stated intent of
improving people's health can be enhanced through tackling the
public health problem of malnutrition.
— Key to tackling the problem is to
develop policy and ensure its co-ordination through action led
by the Department of Health.
2. INTRODUCTION
The Malnutrition Advisory Group (MAG) welcomes
the opportunity to submit evidence to the Health Select Committee
on the public health problem of malnutrition. Malnutrition is
not restricted to developing countries. It is a clinical and public
health problem in the UK, where it is frequently unrecognised
and untreated. In contrast to overnutrition, undernutrition continues
to receive little attention.
There is no co-ordinated policy or approach
to nutrition and the detection and management of malnutrition
in the UK. There is a danger of malnutrition becoming "everybody's
concern but no one's responsibility". As a result this paper:
— outlines the problem of malnutrition
in the UK;
— suggests objectives for a nutrition
policy to help detect and manage malnutrition; and
— recommends some actions that could
be taken by Government, NHS and social service departments.
3. THE MALNUTRITION
ADVISORY GROUP
3.1 Background
The British Association for Parenteral and Enteral
Nutrition (BAPEN) is a multidisciplinary association and registered
charity that was formed in 1992 as a result of recommendations
made by the important Kings Fund Report "A Positive Approach
to Nutrition as Treatment". The Association's aim is to improve
the nutritional treatment of the sick who are, or who are likely
to become, malnourished as a consequence of their illness.
Concern among academics and health professionals
over the lack of awareness of the problems of malnutrition and
inappropriate management, have led the British Association for
Parenteral and Enteral Nutrition (BAPEN) to establish the Malnutrition
Advisory Group as an associate group of BAPEN.
The advisory group comprises the following healthcare
professionals, academics and key opinion leaders:
— Mrs Janet Baxter, Nutrition Support
Co-ordinator, Ninewells Hospital and Medical School, Dundee;
— Dr Marinos Elia, (Chairman) Clinical
Scientist and Honorary Consultant Physician, Addenbrooke's Hospital,
Cambridge, and Churchill College, University of Cambridge;
— Professor Alan Jackson, Professor
of Clinical Nutrition, Southampton General Hospital;
— Ms Pamela Mason, writer and consultant
pharmacist;
— Mrs Hazel Rollins, Nutrition Nurse
Specialist, Luton and Dunstable Hospital;
— Dr John Sandars, GP and Lecturer
in General Practice, Wilmslow, Cheshire;
— Dr Adrian Thomas, Consultant Paediatric
Gastroenterologist, Booth Hall Children's Hospital, Manchester;
— Mrs Jill Ward, Manager, Nutrition
and Dietetic Services, Rotherham General Hospitals NHS Trust;
and
— Patients Association representative
to be replaced.
3.2 Objectives
The Malnutrition Advisory Group was set up to:
— raise the profile of malnutrition
among healthcare professionals and in the media;
— ensure that appropriate priority
and action is given to the area by primary healthcare professionals,
particularly GPs and purchasers;
— communicate the benefits of timely
and appropriate use of nutritional supplements for patients;
— produce definitive guidelines for
the management of malnutrition in the community; and
— work nationwide with key influential
groups to promote standards of excellence in the management and
treatment of malnutrition within each National Service Framework.
3.3 Activities
3.3.1 Guidelines
Guidelines for the detection and management
of malnutrition in the community are currently being compiled
with the aim of launching later this year. The objective of the
guidelines is to provide a simple, comprehensive, practical and
scientifically rigorous framework that can be adopted for standard
use throughout the UK.
Valuable comments have been received from a
wide range of multi-disciplinary opinion leaders, health professionals
and organisations including British Geriatric Society, British
Nutrition Foundation, Royal College of Midwives, Royal College
of Nurses and Royal College of Paediatrics.
The guidelines are now in the process of being
updated to incorporate these comments. The group is in the process
of seeking ethics approval to pilot the guidelines to determine
validity, reproducibility and practicability. Piloting is expected
to take place in a hospital outpatient department and in general
practice over the summer months.
3.3.2 Raising awareness
The MAG is actively engaged in raising awareness
of the issues surrounding malnutrition and nutrition with politicians,
policy makers, health professionals and civil servants.
3.3.3 Joint Working
The MAG is seeking to work closely with all
agencies and organisations, including the DoH, to ensure that
malnutrition is minimised.
4. UNDERNUTRITION:
A NATIONAL HEALTH
PROBLEM
4.1 Definition
Malnutrition can be divided into undernutrition
and overnutrition and may be defined as follows: a state of nutrition
in which deficiency or excess (imbalance) of energy, protein and
other nutrients cause measurable adverse effects to tissue, body
structure and function and clinical outcome. This document focuses
on chronic protein energy undernutrition.
In adults, body mass index (BMI: weight (kg),
height2 (m2)) provides a useful indication of a patient's chronic
protein energy status. Adults are considered to be underweight
when they have a BMI <20kg/m2. Unintentional weight loss of
>10 per cent over six months also suggests a high probability
of undernutrition. [11]
[12]
In children, a weight of less than 85 per cent of ideal body weight
for height and/or deteriorating growth suggests undernutrition.
4.2 National figures
In England and Wales 6.9 per cent[13]
of women and 4.2 per cent[14]
of men are underweight. In Scotland, the corresponding figures
are even greater: 8.7 per cent[15]
of women and 5.1 per cent[16]
of men. Therefore the total number of people who may be at risk
of malnutrition in England, Scotland and Wales is 3.2 million.[17]
4.3 Specific groups
Recent studies have indicated that in the community
11 per cent[18]
of patients who have had major surgery, 10 per cent of cancer
patients and 10 per cent of patients who have chronic disease
of the lung, gastrointestinal tract or nervous system are considered
malnourished, [19]
with the prevalence increasing as the disease progresses. These
studies used BMI <20kg/m2 and anthropometric measurements to
identify patients at risk of malnutrition. Amongst the elderly,
between 3 per cent and 6 per cent of free-living and up to 16
per cent of institutionalised individuals are considered to be
at risk of suffering from malnutrition (BMI <20) [20]
and the incidence of specific micronutrient deficiencies is even
higher. [21]
This could mean that of the 150,000 people aged over 75 in long-term
care, 24,000 are malnourished.
4.4 Hospital admissions
The annual hospital admission rate in the UK
represents between 10 per cent[22]
and 15 per cent[23]
of the population. [24]
It is surprising that the incidence of undernutrition in hospitalised
patients is not accurately known. [25]
However, it is estimated that up to 40 per cent of adults admitted
to general medicine, general surgery, respiratory medicine, medicine
for the elderly and orthopaedic surgery are malnourished. [26]
Among the elderly the proportion is as high as 60 per cent. [27]
For children, studies have indicated that around 15 per cent are
undernourished on admission to hospital. [28]
In many cases, the nutritional status patients who are already
malnourished continues to decline after admission[29]
so that it is worse at time of discharge. The community is the
main "reservoir" of malnutrition.
4.5 Socio-economic status
The incidence of undernutrition appears greater
in lower social classes. [30]
It is also suggested by the lower birth weight of babies born
to mothers of lower social classes and the greater likelihood
of nutrient deficiencies resulting from a lower intake of anti-oxidants,
vitamins and minerals. [31]
5. CAUSES OF
UNDERNUTRITION
5.1 Disease
Disease is one of the major causes of undernutrition
in the UK. This is not only because it causes tissue catabolism
but also because it causes loss of appetite and problems with
ingestion, digestion and absorption of food.
5.2 Physical Problems
Disease may also lead to a variety of physical
disabilities such as muscle weakness and serious deficits (eg
poor eyesight), which cause difficulties with shopping, working
and/or eating.
5.3 Psychosocial problems
Loneliness, depression, confusion (which can
be precipitated by drugs) and bereavement are also major causes
of malnutrition and drug addiction also is a well known risk factor
especially amongst the elderly. In children common causes of undernutrition
are behavioural and eating problems.
Social isolation, disability, immobility and
poverty can also contribute towards malnutrition, and in turn
can reduce people's incentive to eat, their access to food and
can segregate them from the attention of health and social services.
[32]
Poor housing with inadequate cooking and refrigeration facilities
can also contribute to a poor diet.
5.4 The malnutrition carousel
Malnourished individuals move between hospital
and the community on a "malnutrition carousel" at an
increased rate as they have a hospitalisation rate up to 26 per
cent higher than adequately nourished people. [33]
Up to a quarter of malnourished patients admitted to hospital
are considered to have "severe" malnutrition in some
hospitals. [34]
The nutritional status of the majority of these patients deteriorates
further during hospitalisation. [35]
6. CONSEQUENCES
OF UNDERNUTRITION
6.1 Physiological and clinical
Undernutrition affects every system of the body
and has adverse effects on physical and psychological well being.
The following are among the physiological and
clinical detriments of undernutrition:
— impaired immune response, predisposing
to infection;
— reduced muscle strength and fatigue-contributing
to inactivity, inability to work effectively and poor self-care;
— reduced respiratory muscle strength,
leading to poor cough pressure, predisposing to and delaying recovery
from chest infection;
— inactivity, especially in bed-bound
patients predisposing to pressure sores and thromboembolism;
— impaired thermoregulation, leading
to hypothermia, especially in the elderly;
— impaired wound healing and recovery
from illness, increasing hospital stay and delaying return to
work; and
— foetal and infant programming predisposing
to common chronic disease such as cardiovascular disease and diabetes
in adult life.
6.2 Psychological
Undernutrition, even when uncomplicated by disease
causes apathy, depression, self neglect, loss of libido and social
interactions. It also impairs mother-child bonding.
6.3 Impact
Under nutrition predisposed to disease and adversely
affects its outcomes. Apart from the adverse effects on the individual
it has direct and indirect effects on the community, especially
on the over-stretched NHS.
7. UNDERRECOGNITION
AND UNDERTREATMENT
Often the symptoms of undernutrition are multiple
and non-specific. They are often entirely attributable to underlying
disease. The result is that undernutrition is often unrecognised
and untreated. In a number of key environments, large numbers
of patients are malnourished and this has not been recognised
in hospitals, [36][37][38][39]
outpatients, [40]
nursing homes[41]
and in the community. [42][43]
For example, a recent study in Glasgow concluded that 70 per cent
of malnourished patients admitted to hospital were not recognised
as being malnourished. [44]
Other studies in the community conclude that 15 to 50 per cent
of children with failure to thrive are never identified as such.
[45][46]
8. TREATING UNDERNUTRITION
8.1 Management
The key elements of effective treatment are
the following: identifying patients with malnutrition or at risk
of malnutrition, controlling the underlying disease and associated
physical/psychosocial problems, and using appropriate and timely
intervention by the simplest means possible. This means that effective
treatment usually begins with ordinary food and progresses to
food supplements and in a few cases to artificial nutritional
support such as delivering nutrients by enteral feeding tubes.
8.2 Clinical consequences of treatment
There is considerable evidence that nutritional
intervention reduced morbidity and mortality in both hospitals
and the community. [47]
For example, the use of supplements in undernourished free-living
patients produces a variety of benefits depending on the condition;
improved muscle strength, walking distance and well being in patients
with chronic obstructive airways disease; reduced falls and increased
activity of daily living in the elderly; improved growth in children
with cystic fibrosis and improved immune function in patients
with HIV. [48][49]
9. COSTS TO
THE NHS
9.1 Community
The main burden of malnutrition falls on the
community. Studies suggest that people with gastrointestinal,
respiratory and neurological disease-related malnutrition have
a 6 per cent higher GP consultation rate, are given an additional
9 per cent more prescriptions and have a 26 per cent higher hospital
admission rate than others. [50]
This costs an estimated £7.3 million per 100,000 such patients
per year. [51]
It is estimated that up to 12,000 patients were
receiving home enteral tube feeding in the community at any one
time in 1998 (usually under the supervision of carers).[52]
Such treatment in hospital would cost over £0.5 billion per
year extra. [53]
The indirect costs to the community and the
pressure on carers are difficult to evaluate (eg through loss
of work, reduced work performance).
9.2 Hospitals
The King's Fund has estimated that in excess
of £260 million (1992 figures) could be saved each year if
all undernourished patients were given appropriate nutritional
intervention. [54]
One study demonstrated that if patients undergoing surgery were
given adequate nutritional intervention, the length of stay in
hospital would be reduced by half[55]
and £233 would be saved for each inpatient day. [56]
9.3 Burden of illness
At a conservative estimate the cost of undernutrition
is in excess of £1 million per year per average parliamentary
constituency. As well as direct costs on the NHS there are other
costs such as social care, lost work days and disability benefits.
This total does not take into account the effect malnutrition
has on decreased work performance.
9.4 The cost effectiveness of intervention
Evidence is growing that nutritional intervention
can release resources in the health service. American data suggest
that if patients are given appropriate nutritional intervention
the length of stay in hospital can be reduced by up to five days
and $1 million could be saved for the average hospital. [57]
10. WHY DOES
UNDERNUTRITION EXIST?
10.1 Diffuse nature of undernutrition
Undernutrition affects every medical speciality.
Diffusion of responsibility and lack of expertise contribute to
the problem.
10.2 Education and training
A MORI survey commissioned by the Malnutrition
Advisory Group found that 60 per cent of GPs felt that they needed
further training in malnutrition and 74 per cent of GPs had received
no undergraduate training in nutrition. [58]
10.3 Lack of awareness
In the same MORI survey 30 per cent of GPs did
not associate "disease related malnutrition", with weight
loss and only one third received regular information on nutrition.
[59]
A survey of practice nurses in South London found that no nurses
had been on nutrition or dietetic related training courses.[60]
10.4 The impact
Undernutrition is frequently unrecognised and
untreated, with adverse effects on the individual, family and
community.
11. MALNUTRITION
AND HEALTH
POLICY
11.1 Policy and co-ordination
Government policy on the management and detection
of malnutrition is under-developed. In the key area of screening
and detection of malnutrition—especially among the key at-risk
groups such as the elderly and those with chronic diseases—there
is no national guidance or policy.
There are several initiatives that address some
of the issues concerned with malnutrition and there are government
initiatives that have dietetic input. However, there is no overall
nutrition policy which integrates:
1. primary, secondary and tertiary care;
2. clinical care and public health nutrition;
3. undernutrition and overnutrition; and
12. RECOMMENDATIONS
These recommendations suggest areas for action
and explain how actions could be co-ordinated through implementation,
monitoring and inter-agency working.
It is important that any action is measurable
through a set of robust indicators to allow monitoring and acquisition
of information for corrective action where necessary.
Prompt action could assist the Government in
improving the health of patients in the recently announced priority
areas of cancer and cardiac care.
12.1 Policy
12.1.1 Recognition of the malnutrition problem
Recognition by various Government departments
that undernutrition is a public health problem is a pre-requisite
for appropriate action. It is encouraging that COMA has recognised
this. [61]
Malnutrition is a major UK health problem and it is crucial that
the Department of Health relays this to the NHS, health professionals
and patients.
Prompt action is needed to counter the problem
of malnutrition, especially in the community.
12.1.2 Key areas for action
Policy should aim to identify, treat and manage
malnutrition in the health service, especially in the community.
Policy should include:
— nutritional considerations, especially
the reduction of malnutrition, should play a role in all aspects
of the clinical governance framework;
— the detection, management and treatment
of malnutrition should be a part of any relevant public health
policy or initiative;
— patients should be screened for malnutrition
in general practice and on admission to hospital using evidence-based
guidelines;
— patients should receive appropriate
nutritional intervention where malnutrition is detected; and
— robust indicators need to be established
to ensure policy is effectively implemented.
12.2 The Minister of Public Health to co-ordinate
policy to reduce malnutrition
The Minister for Public Health should co-ordinate
nutritional aspects of public health policy and be accountable
to Parliament for the reduction in prevalence of unnecessary malnutrition
in England. The minister should:
— co-ordinate and promote nutrition
in health policy and initiatives;
— reduce the incidence of unnecessary
malnutrition by prevention, early detection and appropriate management
of malnutrition;
— cover all areas of nutrition including
overnutrition as well as undernutrition; and
— ensure that people receive appropriate
nutritional intervention where required.
Annex 1 outlines specific responsibilities in
detail.
12.3 Policy Officer in the Department of Health
A senior civil servant should be given specific
responsibility to support the minister and to help with the co-ordination
of policy on nutrition with the aim of reducing the incidence
of malnutrition in the UK.
12.4 Local bodies should co-ordinate and implement
policies to reduce the incidence of malnutrition
12.4.1 Health Authorities
Health authorities have an important role in
monitoring and maintaining the public health in their areas. Health
authorities should:
— monitor the incidence of malnutrition
as part of their public health function;
— report on the problem of malnutrition
in their annual reports;
— ensure that nutrition and the prevention
of malnutrition is included in health improvement programmes;
and
— work jointly with PCTs/PCGs to reduce
the incidence of malnutrition in their area.
12.4.2 Primary Care Groups/Primary Care Trusts
To help co-ordinate and enforce policy PCGs
and PCTs should ensure that:
— all GPs in their areas screen all
key patient groups at risk;
— when conducting audits of patient
records, relevant nutritional information for each patient is
effectively recorded; and
— when PCTs/PCGs commission patient
services nutritional care also should be included.
12.4.3 Hospitals trusts
All hospital trusts should ensure that:
— patients are screened for malnutrition
on admission and before discharge; and
— on discharge a patient's nutritional
requirements are effectively communicated to care agencies (social
services, PCGs etc) in the community.
12.5 Agencies should monitor the co-ordination
of policy
12.5.1 The Commission of Health Improvement
(CHImp)
In the monitoring of health services CHImp should
give attention to the co-ordination of policy.
12.5.2 The Audit Commission
The Audit Commission should be commissioned
to conduct a qualitative study of the co-ordination of policy
nationwide.
12.5.3 Community Health Councils (CHCs)
CHCs should be encouraged to monitor the co-ordination
of nutrition policy in their local areas.
12.5.4 Social Services Inspectorate (SSI)
The Social Services Inspectorate should incorporate
nutritional screening into its inspection programme for older
people's homes and social service departments.
12.6 Management information to monitor and
co-ordinate
Monitoring the co-ordination of policy is necessary
to inform progress. For policy to be co-ordinated effectively
robust outcome indicators must be set. These must be included
in existing data sets, be monitored by health authorities and
be included as part of public health data returns.
The problem of effectively monitoring malnutrition
to ensure that policy is co-ordinated to reduce it needs attention.
Possible information indicators, which could show the effectiveness
of policy co-ordination, could include:
— recording the number of people who
are admitted to hospital with some form of malnutrition. Malnutrition
and significant weight loss should be recordable as part of a
clinical diagnosis on admission to hospital; and
— reporting rates of malnutrition in
each health authority area.
12.7 Education and training of health professionals
The training and education of health professionals
is very important and is a necessary part of any public health
initiative. Only once health professionals are aware and educated
can the problem be effectively tackled.
12.7.1 Raise awareness
Key to tackling malnutrition in Britain is raising
awareness of the importance of nutrition in the prevention and
treatment of disease. This should be done through health authority
public health leads, PCG training leads and in co-ordination with
hospital trusts.
12.7.2 Education and training
In the MORI survey conducted by the MAG, six
out of 10 GPs said that they needed a substantial or a fair amount
of additional training in nutrition. [62]
Therefore:
— education and training of GPs and
members of the primary health team is urgently needed; and
— co-ordinated with the relevant training
leads on PCGs/PCTs, health authorities and professional organisations
(eg Royal Colleges).
12.7.3 Guidelines for the detection and management
of undernutrition
To help health professionals identify, detect
and manage malnutrition, evidence based guidelines are required.
The MAG is in the process of working on producing evidence based
guidelines for the detection, management and treatment of malnutrition
in the community. These guidelines could provide a useful tool
to help health professionals in the fight against malnutrition.
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Department of Health, Health Survey for England 1996. HMSO, 1998.
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Scottish Office, Scottish Health Survey 1995. The Stationary
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