Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by The Malnutrition Advisory Group (PH 33)


  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


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.


  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

    4.  adults and children.

  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.


  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.


3.1  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.


4.1  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]


5.1  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]


6.1  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.


  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]


8.1  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]


9.1  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]


10.1  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.


11.1  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

    4.  adults and children.


  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.

11   Elia M, Lunn P G. Biological markers of protein-energy malnutrition. Clin Nutr 1997; 16 (Suppl 1): 11-17. Back

12   Malnutrition Advisory Group, Guidelines for Detection and Management of Malnutrition in the Community, 2000 (in press). Back

13   Ibid, 300. Back

14   Department of Health, Health Survey for England 1996. HMSO, 1998. 299. Back

15   Scottish Office, Scottish Health Survey 1995. The Stationary Office, 1997. 274. Back

16   Ibid. Back

17   Adapted from Government Statistical Service figures. Back

18   Edington J, Kon P, Martyn C. Prevalence of malnutrition in patients after major surgery. J Hum Nutr Dietet 1997; 10: 111-116. Back

19   Edington J, Kon P, Martyn C. Prevalence of malnutrition in patients in general practice. Clin Nutr 1996; 15: 60-63. Back

20   Department of Health, National Diet and Nutrition Survey; people aged 65 years and over. HMSO, 1998. Back

21   Ibid. Back

22   Rowlands O, Singleton N, Mager J, Higgins V. Living in Britain, results from the 1995 General Household Survey, Office for National Statistics, 1997. Back

23   Elia M. Artificial nutritional support in clinical practice in Britain. J R Coll Phys 1993; 27: 8-15. Back

24   Department of Health, Statistical Bulletin 1998 NHS hospital activity statistics: England 1987-88 to 1997-98. Back

25   Stratton R, Elia M. How much undernutrition is there in British Hospitals? British Journal of Nutrition (in press). Back

26   McWhirter J P, Pennington C R. Incidence and recognition of malnutrition in hospital. BMJ 1994; 309: 945-948. Back

27   Sullivan, D H, Sun S, Walls, R C. Protein-energy undernutrition among elderly hospitalised patients, a prospective study. JAMA 1999, 281:21: 2013-2019. Back

28   Hendrikse W H, Reilly J J, Weaver, L T. Malnutrition in a Scottish Children's Hospital, J Hum Clin Nutr 1980:30: 1140-1146. Merritt R J, Suskind R M Am J Clin Nutr 1979; 32:1320-1325. Parsons, Francouer, T M, Howland P, Plenger R F, Penchartz P B. Am J Clin Nut 1980: 30; 1140-1146, Moy R J D, Smallman S, Booth I W. Malnutrition in a UK children's hospital, J Hum Nutr Diete 1990: 3; 93-100. Back

29   McWhirter J P et alBack

30   Edington J, Kon P, Martyn C. Prevalence of malnutrition in patients in general practice. Back

31   Acheson D (chairman). Independent Inquiry into Inequalities in Health Report. HMSO London 1998. Back

32   Allison S P, Hospital Food as Treatment. A report by a Working Party of BAPEN, 1999. Back

33   Martyn C N, Winter P D, Coles S J, Edington J. Effect of nutritional status on use of health care resources by patients with chronic disease living in the community. J Clin Nutr 1998; 17: 119-123. Back

34   McWhirter J P, et alBack

35   McWhirter J P, et alBack

36   Mowe M, Bohmer T. The prevalence of undiagnosed protein-calorie undernutrition in a population of hospitalised elderly patients. Journal of American Geriatric Society 1991; 39:1089-1092. Back

37   Consumer's Association, Malnourished inpatients: overlooked and undertreated. Drugs and Therapeutics Bulletin 1996; 8:57-60. Back

38   ACHCEW, Hungry in hospital? Health News Briefing, ACHCEW, London. Pp1-29. 1997. Back

39   McWirther et alBack

40   Miller D K, Morley J E, Rubenstein L Z, Pistruszka F M, Stome L S. Formal geriatric assessment instruments and care of older general medical outpatients. Journal of the American Geriatric Society 1990; 38: 645-651. Back

41   Abbasi A, Rudman D. Observations on the prevalence of protein-calorie malnutrition older persons? Journal of the American Geriatric Society 1993; 41: 117-21. Back

42   Wright C M, Callum J, Birks E, Jarvis S. Effect of community based management in failure to thrive: randomised controlled trial. BMJ 1998: 317: 571-574. Back

43   Bachelor J K A. Failure to find a failure to thrive. Whiting and Bush; London 1990. Back

44   Kelly I E, Tessire S. Cahil A, Morris S E, Crumley A, McLaughlin D, McKee R F, et al. Still hungry in hospital: identifying malnutrition in acute and hospital admissions. Quarterly Journal of Medicine 2000; 93: 93-98. Back

45   Wright et alBack

46   Bachelor et alBack

47   Green C J. Existence, causes and consequences of disease-related malnutrition in the hospital and the community, and clinical and financial benefits of nutrition intervention. Clinical Nutrition (1999) 18/(Supplement 2): 3-28. Back

48   Elia M, Stratton R. A critical systematic analysis of the use of oral nutritional supplements in the community (unpublished). Back

49   Green et alBack

50   Martyn C N, et alBack

51   Adapted from Martyn et al. 1998 and Health Statistics 9th (1995) and 10th (1997) editions. Back

52   Adapted from Elia M et al, Enteral and Parenteral Nutrition in the Community. A Report by a Working Party of BAPEN 1994. Back

53   Adapted from Elia M et al, Enteral and Parenteral Nutrition in the Community. Back

54   Kings Fund Centre. Positive approach to nutrition as treatment: report of a working party. Kings Fund, 1992. Back

55   Mason I, The Case for nutrition in surgery. Hospital Doctor 10 June 1999: 52-83. Back

56   Office of Health Economics. Compendium of Health Statistics, 10th Edition 1997. Table 3.39. Back

57   Tucker H N, Stanley G, Miguel G, Cost containment through nutrition intervention. Nutrition Reviews April 1996. 54: 111-121. Back

58   MORI. Awareness of Disease Related Malnutrition. A Survey Among GPs. September 1998. Back

59   MORI, ibidBack

60   Macey S, Thorpe T, Practice Nurse Census in Lambeth, Southwark and Lewisham. Lambeth, Southwark and Lewisham Health Authority 1998 (Unpublished). Back

61   Coma Bulletin, June 1999. Back

62   MORI, ibidBack

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