Malnutrition has been defined as ‘a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function and clinical outcome’ (BAPEN, 2018a).
In the UK, about 1.3 million older people are malnourished, equating 11% of the population aged over 65 years (BAPEN, 2018a; Malnutrition Task Force (MTF), 2019).
At the same time, globally more than 1.9 billion adults aged 18 years and older are overweight, of which 650 million are obese; in the UK, 64.3% of adults in the UK are affected. The most likely age group affected are people aged between 66 and 74 years (World Health Organization (WHO), 2018; Baker, 2019). In terms of people's health, obesity increases mortality risk, the risk of diseases such as cancer, cardiovascular disease and type 2 diabetes, and consequently brings increased costs to the NHS and society as a whole (Public Health England (PHE), 2017a).
In response to the startling obesity epidemic, PHE and Health Education England (HEE) have developed excellent resources for healthcare workers (HEE, 2019; PHE, 2017b; 2019) to support people in preventing obesity-related ill health and to promote health and wellbeing. These resources provide information on healthy eating such as the Eatwell Plate, guidance on physical activity and support for weight loss interventions.
Nutritional risks
In the midst of public health messages to tackle the problem of overweight and obesity, however, concern is growing that many elderly people are unknowingly putting themselves at risk of malnutrition. An article in a national newspaper (Simmons, 2019) highlighted the issue by suggesting that healthy eating advice is partly to blame for an epidemic of malnutrition in the elderly, because following advice to eat low-fat, low-sugar and low-calorie foods is not relevant to most of the older population. Instead, the emphasis should be on improving calorie intake (Simmons, 2019).
Although the data show that overweight and obesity most commonly affect those in the 66–74-year age group, the figures do not consider frailty (NHS England (NHSE), 2019). According to NHSE (2019), 75% of 75-year-olds in the UK have more than one long-term condition, rising to 82% among 85-year-olds and are therefore likely to have a greater risk of malnutrition. Therefore, the prevalence of malnutrition increases with age and the number of comorbidities and nutritional priorities should shift towards meeting the increased nutritional needs of patients with a long-term conditions or frailty (Agarwal et al, 2013).
As the population of elderly in the UK is rising, with one in four people predicted to be aged 65 years or older by 2050 (Office for National Statistics, 2019), the problem is likely to persist.
Guidelines and screening
More than a decade ago, the European Nutrition for Health Alliance (2006) (including BAPEN) highlighted the causes of malnutrition in the elderly in the community: these included underlying disease, decreased mobility, limited transport to local shops, social isolation and poverty and thus highlighted the need for an integrated approach to tackling malnutrition in this group. Subsequent policy recommendations included (European Nutrition for Health Alliance, 2006):
More recently, the MTF (2017), which was established to address avoidable and preventable malnutrition in older people, re-emphasised the scale of the problem. It highlighted the increased risk of developing malnutrition in the elderly if food is not eaten for as little as 2–3 days and identified signs of malnutrition, which include:
The MTF report also stated that malnutrition is too often overlooked in the elderly as an underlying cause of poor health, with serious consequences for health and wellbeing, and recommended building on practices, such as using validated screening tools, such as MUST and the newly developed online self-screening tool, to help identify adults in the community at risk of malnutrition and who need nutritional advice. The BAPEN Malnutrition Self-Screening website (2018b) also offers advice on slowing down weight loss, for adults who are concerned that they are at risk of malnutrition based on the results of a self-screen, when the patient should report to a health professional, and provides a nutrition factsheet for patients and carers.
The newspaper article (Simmons, 2019) also reported recent local and national initiatives to address the growing issue of malnutrition in the elderly, such as UK Malnutrition Awareness week (14-20 October 2019), co-founded by the MTF in association with BAPEN in 2018. The MTF website provides useful resources, such as the The Nutrition Clock (MTF, 2019), developed in collaboration with health professionals at the University of Manchester and older people in the community.
Other organisations that have produced resources to support and raise awareness of good nutrition and hydration in older people include Age UK Salford (2019) and the British Nutrition Foundation. The latter has published a series of articles (see https://tinyurl.com/MalnutritionAware-2019) to support the eradication of avoidable malnutrition and dehydration in health and care settings and in the community and highlights the issue of malnutrition as a public health concern.
Conclusion
Nurses and other health professionals are being trained to recognise and act on the prevention of obesity-related ill health at every opportunity. They have a fundamental duty of care to provide basic nutrition and hydration to all patients (Nursing and Midwifery Council, 2018; Royal College of Nursing, 2019), with nutritional screening embedded in everyday practice using tools such as MUST and, where appropriate, to initiate a nutritional care plan in healthcare settings (National Institute for Health and Care Excellence, 2017).
However, this article has highlighted that malnutrition is another major public health issue, particularly in adults aged 65 years and older, which should be everyone's concern and responsibility. If the matter is not addressed through increased awareness and training for health workers, including nurses, and the wider community, there is a risk of further decline in the health of the UK's growing elderly population, including an increase in malnutrition-related morbidity and mortality, reduced quality of life and greater costs to the NHS.