Malnutrition: The Public Health Issue overshadowed by Obesity

 A multidisciplinary initiative to close the

gap on malnutrition

                   

Malnutrition is a condition that occurs when a person’s diet does not contain the right amount of nourishment. 

It means ‘poor nutrition’ and can refer to:• under nutrition – when you don’t get enough nutrients• over nutrition – when you get more nutrients than you need

Promoting Good Nutrition Strategy 2011 DHSSPSNI

The prevalence of malnutrition of patient admitted to hospital in NI is 29%

Malnutrition:A global Public Health Issue

Causes of Malnutrition  Cause  Example 

Increased nutritional requirements  • Infection• Involuntary movement• Trauma• Major surgery

Reduced nutritional intake • Dysphagia• Pain 

Increased nutritional losses • Malabsorption• Diarrhoea• Wound exudate

Those at greater risk of malnutrition include people:• Over the age of 65 years• With long-term conditions e.g. kidney disease, chronic lung disease• With chronic progressive conditions e.g. dementia, cancer • Who abuse drugs or alcohol• Who use multiple prescriptions and over-the-counter medications (Polypharmacy)

Causes of malnutrition:Additional risk factors

Risk factor  Example 

Poverty • Inability to access good food• Inability to afford good food

Psychosocial factors • Isolation / Loneliness• Confusion• Depression

• Anxiety• Dementia • Bereavement

Mobility  • Poor mobility • Disability

• Poor transport links• Difficulty accessing local 

shops

Functional constraints • Inability to prepare food• Poor dental / oral health• Sensory disability

• Difficulty using food containers 

• Difficulty reading food labels 

Clinical effects of Malnutrition

 Immunity – Increased risk            of infection 

HypothermiaImpaired gutintegrity andimmunity 

Renal function - loss of ability to excrete Na & H2O

Decreased Cardiac output 

Ventilation - loss ofmuscle & hypoxic responses 

Psychology –depression & apathy 

Anorexia 

Loss of strength

liver fatty change, functional declinenecrosis, fibrosis

Impaired wound healing

Adapted from Nutrition Now Workshop

Consequences of Malnutrition

• Increased risk of – Pressure sores– Respiratory infections– Falls– Complications following surgery– Poor quality of life

• Tripled risk of mortality in older patients in hospital• More than quadrupled risk of mortality 6 months after discharge

Treatment

Financial implication

• £13 billion in the UK in 2007• More than DOUBLE the amount spent on obesity and overweight

• Clinical costs include– 65% more GP visits – 82% more hospital admissions– 30% longer hospital stay 

• Better nutritional care 3rd largest potential cost-saving to NHS

Obesity  Malnutrition0

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NHS expendature on Obesity and Malnutrition 2007

£ bi

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Oral Nutrition

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/10

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/11

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/12

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2011

England Wales Scotland NI

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UK regions: spend per head

Oral Nutritional Supplements

In certain conditions some foods have characteristics of drugs and the Advisory Committee on Borderline Substances (ACBS) advises as to the circumstances in which such substances may be regarded as drugs

Oral nutrition supplements are  prescribable products that can be used as a simple, effective method of providing nutrition support to people who are malnourished.

Joint Initiative

MEDICINES MANAGEMENT DIETITIAN INITIATIVE

The Public Health Agency

Health & Social Care Board

Delivery of enhanced outcomes for patients, ensuring appropriate use of Oral nutritional Supplements  & management of malnutrition which has delivered prescribing efficiencies which can be redirected into patient care

Target Population Targeted sample of GP practices:0.5- 1.94 % of patients registered with these GP practices are on ONS • People who are prescribed oral nutritional supplements who are 

not under the care of trust dietitians 

Intervention

• Offered a individual  Nutritional Assessment  to targeted individuals • Provide nutritional advice , education and care plan• Training 

Food FirstThe ‘food first’ approach is the term used for general dietary guidance to improve food intake.  It includes strategies such as:• Increasing food frequency• Modifying food intake• Fortifying foodsto increase the consumption of energy and nutrient-dense foods and nourishing drinks. 

Strategy Example

Increasing food frequency Little and often, small frequent meals:3 small nourishing meals and 2-3 nourishing snacks daily

Modifying food intake  Swap :• 1 pint of semi skimmed milk to full cream milk for an extra 100kcals• Low fat margarine to butter for an extra 50kcals per slice of buttered bread• Light / diet yoghurt to rich creamy yoghurt for extra 100kcals per pot

Fortifying foods  Extra 100-150kcals:2 teaspoons jam / honeyMatchbox size grated cheeseTablespoon butter / margarineTablespoon double cream

Extra  150-200kcals1 Tablespoon chocolate spread1 Tablespoon peanut butter1 Tablespoon mayonnaise1 Tablespoon desiccated coconut

Measurable Outcomes

Quality ■ 72 practices complete  ■ 1605 patients assessed ■ ‘Food first’ where appropriate

Patient Experience Questionnaire:   ■ 92% of patients reported 

comparable or improved wellbeing following appointment with the dietitian

GP Questionnaire:  ■ 94% GPs very satisfied with 

communication with the practice before the initiative and what the initiative entails

Efficiency

£ 1,008,565

annual efficiency to date in 2014

GP Comment:“A very worthwhile project undertaken with little or no disturbance in the practice. The admin was well organised and the expertise of the dietitian was very appreciated.”

Safety87% patients with MUST ≥2 had stable or increased BMI @ 8/52

94% patients maintained or increased BMI 8/52 after ONS stopped

Patient perception of ONS