Malnutrition translates as “bad nutrition” and can apply to both under and over nutrition, ie being both underweight or overweight/obese, however malnutrition awareness week focuses on the problems associated with under nutrition and this is what I will be discussing in my blog.
Malnutrition Awareness Week is an annual campaign which seeks to raise awareness and increase understanding of malnutrition amongst health and social care workers, community groups and the public so that it can be identified and treated but also prevented. The campaign calls on everyone to become involved in detecting malnutrition by screening themselves, family members, friends and those they look after. This will enable them to be aware of what increases the risk of malnutrition and what they can do do prevent it happening. Self screening resources are available from https://www.malnutritiontaskforce.org.uk/resources/self-screening-resources
Malnutrition is a problem that primarily affects people, especially older people, in their own homes; in fact over 90% of those at risk live in their own homes, which is why it is so important that those who work in the community setting such as primary care physicians and members of the public need to be aware of the signs before the person ends up in hospital. Malnutrition does not just happen because the person does not eat enough; it is multifactorial and as such needs a multi-disciplinary approach. Some causes include mental health disorders, loneliness, diseases such as cancer and chronic lung disease or diseases where absorption of nutrients are reduced, conditions that involve chronic diarrhoea and vomiting and simply changes in appetite. It can also be caused by poor dentition or ill fitting dentures and these are things that can easily be addressed if they are picked up.
Funding for adult social care has reduced significantly over the past few years and there is now an even greater pressure on service providers. It was estimated in 2016 that the cost of malnutrition in Wales was more than £1.4 billion per annum and exceeded £13 billion in the UK as a whole (BDA Older People Specialist Group). As we are an ageing population, the prevalence of malnutrition is likely to rise and that is why action is needed and why malnutrition awareness week is so important.
Signs of malnutrition:
● Unintentional weight loss within the last 3-6 months (5-10% of body weight)
● Increased incidence of falls ● Impaired immunity – more episodes of illness and infection
● Poor wound healing
● Changes in mood, such as anxiety and depression
● Specific nutrient deficiencies
● Feeling tired all the time
● Poor muscle strength
● Reduced quality of life and independence due to falls and hospital admissions
How can a dietitian help?
It is vital that everyone is able to have access to the right nutrition in order to meet their nutritional requirements and optimise their health. Those who are unable to meet these needs through their diet alone should have access to the nutritional support given by a dietitian.
Dietitians play a crucial role in the treatment and management of malnutrition, not just in the hospital setting but in the community, including care homes and the patients’ own homes. We are able to train other health care professionals so that malnutrition can be identified (this involves the use of nutritional screening tools to identify those at risk) and we work alongside other members of the community team, such as physiotherapists and occupational therapists to provide a multidisciplinary approach to treating malnutrition with the aim being to prevent a malnutrition-related hospital admission. This involves, among other factors, ensuring adequate hydration, nutrition, physical activity and adjustments in the home to ensure that the patient is able to access and use cooking facilities safely.
What we do
We train other health professionals involved in community patient care: We use nutritional screening tools when patients are admitted to hospital to identify those at risk of or suffering from malnutrition and these screening tools are transferrable to the community setting and are used widely. Patients should be screened upon registration at their GP practice, at outpatient appointments in their own homes or in hospital and weekly in care homes if there is a clinical concern or monthly for monitoring. Dietitians and also some dietetic support workers are able to provide training in the primary care setting on how to use screening tools effectively and what steps to take if someone is identified as needing intervention.
We conduct thorough nutritional assessments:
We give “food first” advice:
In the community setting, it is important to enable people to feel empowered to manage their conditions and a part of this is providing them with the information they need to try to gain weight and improve their nutritional status. The “food first” approach involves looking at their current diet and identifying where high calorie/protein additions (fortifications) can be made without increasing the volume significantly. If someone is struggling with a poor appetite, the last thing that would be helpful would be to advise them to increase the size of their meals because they would not be able to manage it and it may impact their appetite further if they feel overfaced. An example of food fortification would be to add cream to a bowl of soup and sprinkle grated cheese on top. We also advise the little and often approach, which involves breaking down the standard three meals a day into smaller, more frequent meals so that nutrition is optimised and we can provide information and ideas on suitable snacks to have during the day, as well as before bedtime. For example, a 200ml glass of full cream milk alongside a couple of biscuits can provide approximately 330kcal and 8-10g of protein. We also provide written information so that the patient always has something to refer to in-between appointments and they will be reassured that they can always contact us if they have any questions or concerns.
We can request nutritional supplements:
If, during our initial assessment and also during follow up appointments, we identify a large nutritional deficit that we do not feel will be met with food alone, we can either prescribe (if we are a supplementary prescriber) or request with the patient’s GP, nutritional supplements. These are usually only prescribed for a fixed term to enable the patient to gain weight and improve their nutritional status but they will be available until the nutritional goals are met or to maintain weight in chronic diseases. We will discuss preferences with our patient as the supplements are available as milk based or juice based and their preferred flavours will also be discussed. There is little point in requesting or prescribing drinks that they will not take because they do not like milk or dislike chocolate flavour so having that discussion is important.
We check fluid intake:
Dehydration is a known cause of falls among the elderly in the community and if the risk of falls is increased, the risk of immobility or a hospital admission is increased. If a patient is already struggling to prepare their meals or eat enough to provide sufficient calories and protein, a fall will only worsen this. If the person is in pain, their appetite will be affected and if they lose their mobility and do not have anyone to help them, their intake will reduce further and they will become more malnourished. They will then be at an increased risk of further falls or malnutrition related illnesses. Additional effects of dehydration include increased risk of constipation, urinary infections and a sore mouth which will all impact on appetite.
As part of our assessment, we will ask how much fluid they are drinking a day and will then offer advice on how to increase this if needed, with the aim being 6-8 glasses daily. Some elderly patients feel anxious about drinking too much due to incontinence and this is important to acknowledge and address. Water, tea, herbal tea, coffee and squash all count as fluids, however 20-30% of our daily fluids come from foods, therefore soup, jelly and some vegetables and fruits such as melon can all count towards our fluid intake.
As I have highlighted, dietitians play a vital role in the identification, treatment and prevention of malnutrition but we can all contribute and this is the reason for Malnutrition Awareness Week. We can all get involved by using the fantastic resources on the Malnutrition Taskforce website and ensuring that we look out for the signs of malnutrition in ourselves, our loved ones and those we look after. There are so many reasons to be highlighting the importance of tackling malnutrition and this week provides an excellent opportunity to do so.