Nutrition moves up the agenda

With an estimated cost of £13 billion, malnutrition is an expensive, yet preventable, public health problem. More than seven million people in England are vulnerable to malnourishment. This covers those in hospitals, care homes, sheltered accommodation and others dependant on someone else for their food and water needs¹. 

Malnutrition is associated with poor wound healing, impaired immune responses and a delayed recovery from illness and correcting it has many benefits. These include improved disease recovery, fewer complications and shorter hospital stays reducing the burden on the already strained NHS and improving the health of the nation². 

KEY ROLE OF DIETITIANS
Dietitians, with their training and expertise in nutrition, clearly have a key role to play in the prevention of malnutrition in healthcare settings. The British Dietetic Association (BDA), the professional association for dietitians, has members who work with patients who are at risk or already undernourished. Some of these dietitians work in NHS catering, impacting the nutritional intake of patients in a hospital or group of care homes.

Other members work within private companies involved with food and catering or the production of meal replacement products, impacting areas including the training of chefs and the publication of guidance for caterers. The BDA also has specialist groups who campaign for better nutrition in hospitals and other care settings, including Food Counts made up of dietitians who work in or have an interest in catering, and the Parenteral and Enteral Nutrition Group, whose members work with patients requiring tube feeding.

HOSPITAL FOOD
There is activity concering the food and malnutrition agenda in the UK. National governments are giving good quality, nutritious hospital food a greater priority and malnutrition is recognised as a key clinical risk factor. In 2007 the Department of Health alongside Nutrition Summit organisations, including the BDA, agreed a range of options and recommendations for tackling malnutrition. The resulting Nutrition Action Plan (NAP)³ outlined five key priorities for action. The first priority was to ‘raise awareness of the link between nutrition and good health and that malnutrition can be prevented.’

Dietitian and BDA member Rick Wilson chaired the NAP group looking at raising awareness, developing the ten key characteristics of good nutritional care so that they are applicable across all care settings.

Launched in 2007, the ten key characteristics are a distillation of over 100 recommendations made at the Council of Europe resolution on food and nutritional care in hospitals. They were developed to ensure that hospitals and healthcare staff deliver safe and effective nutritional care to patients in hospitals.

Further, the BDA worked closely with the National Patient Safety Agency to develop factsheets for all healthcare staff and care caterers, outlining each characteristic and how to ensure standards are met.

EARLY DETECTION
Incidences of malnutrition are reduced by early detection via routine screening of vulnerable ‘at risk’ groups. Screening identifies those who would benefit from dietary support measures and nutrition intervention. Since 2007, the BDA has worked closely with the British Association for Parenteral and Enteral Nutrition (BAPEN) on the annual Nutritional Screening Survey. The survey, which takes place in BAPEN’s Nutrition Screening Week (NSW) was the first national survey of malnutrition on admission to hospital and care in the UK. In the third (winter 2010) survey, malnutrition was found to affect more than one in three adults on admission to hospitals, more than one in three admitted to care homes in the previous six months and one in five on admission to mental health units⁴. 

Despite efforts from bodies including the Council of Europe, National Institute for Health and Clinical Excellence (NICE) and the Department of Health Nutrition Action Plan, the NSW10 survey found there are still a variety of nutritional screening policies and practices within healthcare settings, exacerbating the problem of malnutrition. With well over 50 published nutrition screening tools, not including those unpublished but in clinical use, there is confusion amongst healthcare professionals and carers about how to recognise and manage malnutrition.

The BDA encourages the use of screening tools which are simple to use, non invasive, concise, acceptable to the client group and linked to an agreed policy on further action. Any tool used should be evidence based, reliable, reproducible, validated and practical with a source of evidence to back up each recommendation made, such as BAPEN’s Malnutrition Universal Screening Tool (MUST)⁵.  

This would allow dietitians and other health professionals to easily identify those at risk in a rapid and consistent manner; providing appropriate nutrition therapy. Furthermore, the closer monitoring of malnutrition risk as a marker for disease progression, allows the earlier and more effective placement of nutrition care measures. NSW10 showed that MUST is now the most commonly used screening tool in all care settings, suggesting the tide is slowly turning.

However vital, screening is only one part of a larger system to tackle malnutrition –  procurement of food, menu planning, acting on the screening results ensuring continuity of care, auditing of screening and care planning and training of staff are all essential. Dietitians are uniquely placed to lead this process as they have a unique understanding of the food, catering and nutritional care system. Dietitians make the connections which ensure the system works for the benefit of patients, reducing demands on staff.

Footnotes
1. HM Government (2010) Nutrition Action Plan Delivery Board end of year progress report [internet]. Available from: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113108
2. The British Dietetic Association (2006) Malnutrition in Hospitals [internet]. Available from: www.bda.uk.com/malnutrition_in_hospitals.html
3. HM Government (2007) Nutrition Action Plan [internet]. Available from: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_079931
4. BAPEN (2011) Nutrition Screening Survey in the UK and Republic Of Ireland in 2010 [internet]. Available from: www.bapen.org.uk/pdfs/nsw/nsw10/nsw10-report.pdf
5. BAPEN (2003) The MUST Report Executive Summary [internet]. Available from: www.bapen.org.uk/must_report.html