Thin end of the wedge

18/12/2014 - 09:37
Obesity grabs all the headlines when it comes to diet and health, but its alter ego malnutrition insidiously causes more suffering and exacts a greater financial toll on society. David Foad reports.

At a UN summit in Rome in November, more than 170 governments from around the world pledged to do more to prevent malnutrition, including the adoption of guidelines to promote healthy diets.

The meeting heard that currently two billion people – almost a third of the world's population – suffer from nutritional deficiencies, including vitamin A, iodine, iron and zinc. And such deficiencies were blamed for 45% of all child deaths in 2013.

So far, so familiar for many in the UK, who continue to believe that malnutrition is a developing-world problem and that we, in the more affluent west, have a bigger health worry in obesity.

However, according to Age UK, there are a million people over the age of 65 suffering from untreated malnutrition in their own homes. That is one in ten, while the population of those in this age group is forecast to rise by nearly 50% over the next 20 years to 16 million.

And if you extend the criteria to those believed simply to be at risk of malnutrition, then the current figure triples to three million.

This makes malnutrition not only a significant problem right now, but also one that is likely to grow and provide a further drain on already-stretched medical resources because we are an aging population.

Age UK’s Dianne Jeffrey, who also heads the Malnutrition Task Force, says: “Malnourished people see their GP twice as often, have three times the number of hospital admissions and stay in hospital more than three days longer than those who are well nourished upon admission.”

It may be difficult to put a precise figure on the cost of treating these health problems, but Dr Tim Bowling, president of BAPEN (British Association for Parenteral and Enteral Nutrition), says his organisation estimated it to be £15 billion a year, according to the most recent figures.

“The malnourished cost a lot. They are more likely to fall ill, stay longer in hospital and cost four times as much to treat as a well-nourished patient with the same condition.”

And it’s not just the elderly and vulnerable in the community who are at risk, hospital patients and care home residents can also suffer.

Bowling says BAPEN’s most recent malnutrition screening week involved 78 care homes with 523 residents.

“The rate of malnourishment ranged from 30% to as many as 42% in the care homes. The equivalent figure for free-living elderly people would be about 10%.”

Part of the problem seems to be that relatives and even professional carers assume that losing weight is a natural part of the aging process and don’t raise the alarm.

Dr Lisa Wilson, a public health nutritionist who has worked for the International Longevity Centre and the Caroline Walker Trust, says: “It’s not normal to get thin as you get older.”

“For many of us working in the health and social care sector, the need for good-quality, nutritious food across all care settings is not only a key driver in our work, but something we are often surprised we still have to highlight as an issue.

“My experience working with older people has taught me that part of the problem is language. It is not normal to get thin as you get older, something that is echoed by work carried out by the Malnutrition Task Force in 2013.

“In it, older people said they did not equate their experiences or those of their peers as being related to malnutrition.

“But all of them could identify with weight loss, lack of appetite and reduced interest in food.

“I think this is the case for many in the care sector, who regularly see older people losing their appetite or interest in food through ill health or circumstance.”

Dianne Jeffrey sums the situation up: “Malnutrition is one of the key issues affecting the health of older people in the UK, yet it remains under-detected, under-treated and under-resourced, and is often over looked by those working with and for older people.”

The toll of malnutrition on people’s health is matched by the toll on the nation’s pocket, and it is the financial case for prevention and early treatment that is beginning to see action.

Malnutrition Task Force data indicates that malnourished patients who visit their GP incur an additional health care cost of £1,449 each following diagnosis.

The group puts the direct health care costs of treating malnutrition at more than £5 billion, a figure that rises to closer to £15 billion when associated health and social care spending is factored in.

A study by the National Institute for Health & Care Excellence (NICE) estimated in 2012 that investing malnutrition screening and early intervention promised a saving of £71,800 for every 100,000 population in the average Primary Care Trust.

In fact, it costs the NHS £225 a day per patient just for them to occupy a bed, a figure that rises dramatically when food and treatment costs are added.

In 2006, NICE calculated that the cost for England alone of fully implementing guidelines on screening for malnutrition was £32 million a year – a fraction of NHS spending of £109.7 billion in 2013–14, according to figures from the NHS Confederation.

Dr Wilson says: “As part of our work, we need to understand how the people we care for see themselves. If left untreated, malnutrition can lead to related illnesses, complex treatments, prolonged recovery periods delays in hospital discharge and increased NHS costs.

“We have up to three million  people at risk of malnutrition in this country, and a recent Dutch study showed that the cost of meals and malnutrition screening was about £3,950 a year per person, much, much less than the cost of treating the effects of malnutrition.”

BAPEN’s Bowling concluded: “There are five principles of good nutritional care that are part of an integrated nutritional strategy supported by BAPEN, the NACC, industry suppliers, patient groups and the medical establishment.

“They are: prevention, screening, treatment, education and training, and management.

“This strategy has to include both malnutrition and dehydration, and involve MUST [Malnutrition Universal Screening Tool] to provide a score that shows the level of risk.

“Treatment is needed to follow up on screening to provide a care pathway that is both individual and transferable from hospital to care home.

“All care staff need education and training, doctors and nurses above all as they are often poorly educated about nutritional issues.

“And, lastly, management needs to improve.”

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