WIREDGOV

Malnutrition is arguably the biggest health risk we rarely think about.

Around 1 in 20 adults in the UK are estimated to be malnourished or at risk of malnutrition, and its impact can be profound. Malnutrition can increase the risk of illness and infection, increase the likelihood of falls, reduce mobility, reduce independence and reduce quality of life. People from the most deprived backgrounds are most affected.

The cost of treating someone who is malnourished is around three times the cost of treating someone who isn’t. Estimates suggest that malnutrition may cost the health and care system as much as £22.6 billion a year. Malnourished people visit their GPs more often, have greater risk of complications in illnesses, and are more likely to need hospital and care home admission.

Estimates suggest that malnutrition may cost the health and care system as much as £22.6 billion a year.

Yet malnutrition is not such a high priority for health care staff, particularly those who do not provide frontline care. Nor is it one of the key health trends mapped by the Office for Health Improvement and Disparities.

Why is that and what, if anything, can be done about it?

To understand the issue, The King’s Fund convened a roundtable, sponsored by Abbott, of twelve professionals involved in preventing, diagnosing and treating malnutrition. Attendees included GPs, allied health professionals, geriatricians, dietitians and staff from community or voluntary sector organisations.

Some clear, linked issues emerged.

First, nutrition is such a basic, fundamental element of our lives that it does not feel like a ‘medical’ issue at all. What we eat is not something that we feel we need to consult a GP about and may not be an area that a GP feels able to discuss with their patients. It is an ‘invisible problem’. It is only when someone comes into the health care system with a problem – perhaps after a fall or when having treatment for a serious condition such as cancer – that malnutrition may be identified. And by then it may be harder to tackle.

Illness may mean people struggle to get to the shops so don’t have food they feel like eating, while disability may reduce income, which makes it harder to afford nutritious food. 

Second, malnutrition and its causes are complex. At our roundtable, experts talked about the differences between disease-related malnutrition (for example, as a result of heart failure, cancer or cancer treatments) and social malnutrition (for example, where people may not eat because of loneliness or may not eat well because of poverty). There was general agreement, though, that this neat split into disease-related and social malnutrition over-simplifies a situation in which one type of malnutrition can feed into the other. Illness may mean people struggle to get to the shops so don’t have food they feel like eating, while disability may reduce income, which makes it harder to afford nutritious food. There was also discussion about the complex relationship between malnutrition, sarcopenia (muscle weakness) and frailty, and about the relationship between obesity and malnutrition (and how it is quite possible to experience both at the same time).

Third, malnutrition thrives on misunderstandings about health and health norms, particularly as people age. Too many people, including clinicians, see loss of appetite as a normal feature of ageing. And many people don’t understand the basics of nutrition – protein, fats, vitamins, carbohydrates – and what constitutes a healthy diet at different stages of our lives: ‘Should I make my 94–year–old mum eat carrots or is it OK if she eats steam pudding and custard? It is that sort of thing that people really don’t understand.’

Fourth, even when malnutrition is recognised as an issue that goes beyond the individual or their family, it is seen as something that is everyone’s responsibility – the GP, allied health professionals (such as OTs), physiotherapists, local authorities, the voluntary sector. In practice, this means it is often seen as no one’s responsibility – and without a clear lead it too often falls between the cracks as an issue and there is insufficient concerted action. Lack of capacity across the system does not help. As a result, diagnosing malnutrition is, as one participant said, ‘like opening a Pandora’s box' which ‘we shut very quickly’.

If anything, we have reduced the sort of community services that might help in this area, with recent reductions in basic services such as community meals (‘meals on wheels’).

Finally, we intervene far too late in the process. This applies to the treatment of individuals, too many of whom are malnourished when they first present at hospital, for example after a fall. But that is partly because we are not thinking about population health approaches to malnutrition, identifying groups who are most at risk and taking steps to reach them. If anything, we have reduced the sort of community services that might help in this area, with recent reductions in basic services such as community meals (‘meals on wheels’).

However, the situation is far from irredeemable. Our participants put forward a range of proposals for how we can tackle malnutrition more effectively. These included:

• more focus on public education about the fundamentals of nutrition and its impact on health and wellbeing

• greater community focus on early diagnosis and prevention

• improved education for clinicians about malnutrition and sarcopenia, especially in high-risk patient groups, including the elderly and people with conditions such as frailty and oncology

• a clearer sense of who is responsible for identifying and tackling malnutrition and its causes at a national and integrated care board level

• more clarity about the approach to take for different individuals – when is a ‘food first’ approach appropriate and when is it essential to use nutritional supplements?

• better pathways for tackling malnutrition when it is diagnosed, particularly in the community.

Though the group had little time to discuss it, there is also a need to recognise and tackle the broader causes of malnutrition, such as poverty, and the need for a food policy that ensures everyone has access to a healthy diet.

Above all, though, more work to ensure that malnutrition is recognised as a challenge and then to act on it was seen as a prerequisite for progress.