There are an estimated 3 million people in the UK suffering from malnutrition but, despite the public health implications, the issue receives very little attention. So how can awareness be raised?

Denis Campbell
The Guardian, Wednesday 29 May 2013

Domestic carers who only visit an old person’s home once a week may not realise the person they look after is not eating enough. Photograph: BSIP/Universal Images Group Editorial

For some people the word “malnutrition” inevitably conjures up mental images of starving children in Africa. But it is also an issue much closer to home, here in the United Kingdom. About 3 million people in the UK are estimated to either suffer from malnourishment or be at risk of becoming underfed. The resulting problems are believed to cost the public sector several billion pounds, for example from avoidable hospital admissions and extra GP visits for treatments of the range of illnesses malnutrition can cause. The National Institute for Health and Care Excellence (Nice) has identified better nutritional care as the sixth-largest potential source of savings in the NHS.

Awareness of malnutrition in hospitals, care homes and the community has increased in recent years, as have efforts to tackle it. The charity Age UK’s Hungry to be Heard campaign, launched in 2006, highlighted how older people were becoming malnourished while in hospital. In 2011 the Care Quality Commission (CQC), the watchdog of NHS care in England, began assessing how well hospitals were meeting patients’ nutritional needs. The first time CQC inspectors carried out checks, some 17% of hospitals were not helping patients to eat and drink, though by last year that had fallen to 12%. The regulator welcomed hospitals’ progress but also warned about “pockets of poor care”. In 2012, the Malnutrition Task Force, an independent group of experts from the fields of health, social care and dietary advice, was created. It aims to prevent and address malnutrition among over-65s – 1 million of whom are malnourished – wherever it occurs.

Last year Carers UK published a report entitled Malnutrition and Caring: The hidden cost for families. It highlighted how families caring for ill or disabled relatives are struggling to cope with the consequences of malnutrition, such as further deterioration of health.

Despite the size of the problem, progress in persuading politicians both locally and nationally to take malnutrition in the UK seriously has been frustratingly slow. Finding ways to improve this situation formed the basis of a roundtable discussion recently held by the Guardian in association with the medical nutrition company Nutricia. The debate was conducted under the Chatham House rule, which allows comments to be reported without attribution to encourage a frank exchange of views.

To get a better idea of the lack of awareness about the issue, the roundtable heard how just eight of the strategic needs assessments drawn up by England’s 152 local authorities to identify key issues locally have identified nutrition as a problem. As one participant said: “That’s staggering. Think of all the unhappiness and ill-health they could prevent, and all the money they could save, if they picked up malnutrition as an issue.” For example, 15-minute-long visits by domestic carers to older people in their homes may be too brief to let the carer find out why someone is not eating properly, so an opportunity to get to the bottom of a problem is lost, the debate heard.

Although much of the media coverage of malnutrition has focused on hospital staff not ensuring patients eat and drink properly, research by BAPEN, a charity that raises awareness of the problem, shows that 93% of the 1 million older people affected by malnutrition are in the community, 5% in care homes and just 2% in hospitals. “A lot of this is in people’s homes and is thus hidden. We have to make it an issue that people talk about so that people know that other people struggle with it”, said another contributor, who emphasised the need to “make malnutrition something that people can talk about and not feel there’s a stigma about it”.

Much of the discussion centred on malnutrition in older people. A vivid illustration of why came when one of the experts present said that: “Older people’s cupboards can contain only cat food, not food for the person who lives there. This is a massive issue now.” While participants differed in their views on certain issues, they were united in their determination to expose one common belief about older people and nutrition for the misconception that it is. “We need to bust a myth: that it’s normal to lose weight as you age,” said one expert. Another added: “Older people losing weight are often assumed to be normal, so people don’t look for the medical, social, environmental or psychological causes of that”, which can include poverty, disability, loneliness and self-esteem issues.

Medically, malnutrition can be either a cause or an effect of illness. It can be a byproduct of cancer, for example; people taking certain cancer medications may lose their appetite. The same disinterest in food can be seen with those suffering from dementia. Malnourishment can also lead to someone becoming exhausted or even confused, and raise their risk of having a fall or getting an infection and needing antibiotics. The roundtable was told how psychological conditions such as depression, perhaps exacerbated by social isolation – an older person’s family may all live many miles away – can also lead to under-eating.

As most malnutrition happens in the privacy of people’s homes, then it is carers – whether they are relatives, neighbours, volunteers or paid carers – who are most likely to encounter it. The debate heard how diet can become a major challenge in two ways for carers, especially those who spend a lot of time looking after a parent, for example. Six in 10 carers worry about what those they care for are eating, according to a survey of 3,000 carers by Carers UK. More than half of carers said they were neglecting their own diet as a result of their caring responsibilities, while some said they were eating the wrong things because of the stress they are under and more than half said they had experienced problems with diet and hydration. Others did not have the time or the money to eat properly. Those findings add to the existing evidence that carers often neglect their own health. As one of those present said: “Our health service would collapse if it wasn’t for carers, yet carers are facing a challenge of their own”, such as not becoming malnourished like some of those they look after.

A number of those around the table shared their own personal stories of the difficulties they had faced themselves over a loved one’s disinclination to eat or preference for sweet foods of no nutritional value. One described feeling “very helpless, worried, responsible and guilty” over her mother’s reluctance to eat the food she had prepared. “It’s a massive pressure on me,” she added. Another said: “When you have a relative who won’t eat it’s soul-destroying. Mealtimes become a battle.” Several speakers supported a greater use of nutritional supplements to help boost the diet of such people.

Hospitals are vital to tackling malnutrition. A third of older patients are malnourished upon admission and 36% of adult inpatients who need help with eating say they do not always get it. Participants agreed that some hospitals’ policy of excluding relatives from visiting their loved ones during mealtimes was unwise as they could offer assistance which may ensure take-up of the food provided. Patients eating alone in or around their bed was also highlighted as a problem. There was support for bringing back dining rooms and making mealtimes a relaxed and sociable occasion to encourage communal eating. Such initiatives in care homes have seen residents there “blossom”, the event heard.

Participants offered plenty of ideas to address malnutrition, such as an advertising campaign to banish the myth of inevitable weight loss as people age and to ask “do you know what your loved one – or neighbour – is eating?”. Neighbours taking it in turn to cook for each other was also suggested, as was greater use of voluntary organisations to visit isolated older people, check on their welfare and cook for them.

Several changes to NHS practice were proposed, such as hiring more specialist nutrition nurses and shifting resources from hospitals into community-based care. The proposal that GPs should conduct annual assessments of the weight and body mass index of all over-65s, to identify malnourishment as early as possible, sparked a lively debate. While that could help determine the true scale of the problem and lead to those in need being helped, one opponent cautioned that “GPs may end up merely identifying a problem that they can’t solve” and being forced to scale back other work; such assessments would then becoming just another tick-box burden for family doctors.

Recent years have seen some progress on malnutrition, such as Nice guidance and the work of the Dignity Commission, a joint initiative between Age UK, the Local Government Association and NHS Confederation to improve older people’s care in all settings. But participants said they were keen to see more action and soon. “This issue has been around for years but it’s been very difficult to make progress on the public policy side of it,” said a contributor. Certainly all present wanted to see politicians, both locally and at Westminster, give malnutrition much greater priority. As one participant said: “David Cameron has taken a personal interest in dementia through his three-year ‘dementia challenge’. If I was being bold I would say that we need someone at the top of politics to make it their mission to do something about malnutrition, to give it the profile it deserves.”

http://www.guardian.co.uk/social-care-network/2013/may/29/malnutrition-older-people-lack-of-food