1

Malnutrition JSNA September 2016

Overview

Malnutrition (or undernutrition) is a serious global public health problem that is significantly under-

recognised and under-treated1 with associated healthcare costs in the UK exceeding £13 billion annually2.

In the UK, one in three patients admitted to acute care and 35% of those admitted to care homes will be

malnourished or at risk, however 93% of those who are malnourished live in the community3.

There is a lack of local data of the prevalence of malnutrition in Kingston. However, based on national

prevalence of malnutrition it can be assumed that approximately 3,053 older people (>65 years) are

malnourished in Kingston.

In addition to the financial burden of malnutrition, there are numerous adverse outcomes on quality of life

for individuals and their carers. Malnutrition can lead to reduced immune function, decreased physiological

functions, delayed wound healing, increased vulnerability to disease, and prolonged recovery from disease

and injury4. As a result, people who are malnourished have an increased dependence on both primary and

secondary care. For example, people who are malnourished make 65% more GP visits, account for 82%

more hospital admissions and stay in hospital 30% longer when compared with people who are well

nourished5. In addition, malnutrition negatively affects quality of life for both individuals and their carers and

so it is important to both prevent malnutrition and treat it in its early stages.

There can be many contributing factors for malnutrition at an individual level and it can be both a cause and

consequence of ill health. Although specific illnesses or disease processes may play a role, for example

through reducing appetite/intakes, increasing requirements or decreasing the body’s ability to absorb

nutrients, there are other factors including social and psychological influences which may cause or

exacerbate malnutrition. Examples of these include dementia, depression, anxiety, poor access to

transport, poor mobility, poor dentition, taking medication, poverty, social isolation, inadequate care and

substance misuse6.

Various groups of the population can be malnourished or ‘at-risk’ of malnutrition. The focus of this chapter

will be on the over 65’s who are particularly vulnerable to malnutrition, with the UK having an estimated

10% over 65s being malnourished or at risk of malnutrition.

References 1 World Health Organisation (European Food and Nutrition Action Plan 2015-2020). 2 Brotherton, A. and Simmonds, N. on behalf of the BAPEN Quality Group. Malnutrition Matters Meeting Quality Standards in Nutritional Care. Redditch, Worcs. British Association for Parenteral and Enteral Nutrition (BAPEN). 2010. 3 NHS England Guidance – Commissioning Excellent Nutrition and Hydration 2015-2018. 4 NICE Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition Costing report Implementing NICE guidance in England. NICE Clinical Guideline no. 32: February 2006. 5 British Dietetic Association (BDA) Key Fact sheet. Dietitian Key Facts Malnutrition 2014. 6 The Malnutrition Taskforce. Malnutrition in Later Life: Prevention and Early Intervention Best Practice Principles & Implementation Guide. A Local Community Approach. London. Malnutrition Malnutrition Taskforce (2013) Malnutrition in Later Life: Prevention and Early Intervention Best Practice Principles and Implementation Guide A Local Community Approach.

2

Introduction

Malnutrition is defined as a state in which a deficiency or imbalance of energy, protein,

vitamins or minerals causes measurable adverse effects on body composition, function or

clinical outcome1. The word ‘malnutrition’ applies to both over and undernutrition, however in

the context of this chapter, malnutrition will be used to refer to undernutrition.

Malnutrition negatively impacts a person’s quality of life and life expectancy and is estimated

to cost the NHS £13 billion pounds annually to treat2, with total public health and social care

costs in England of £19.6 billion3. This equates to approximately 15% of the total

expenditure on health and social care, although most is attributable to healthcare.

Approximately three million people in the UK are affected by malnutrition at any given time,

the majority (93%) of whom live in the community (including those who live at home or in

sheltered accommodation). A further 5% are living in care homes and just 2% are in

hospital4. Despite the hospital setting accounting for a small proportion of those who are

malnourished, the volume of patient’s means that hospitals remain a vital point of care at

which malnutrition can be identified and treatment initiated5.

Age

Eating disorders (including anorexia, bulimia nervosa and binge eating disorder) are a range

of conditions that are characterised by an abnormal attitude towards food and cause

someone to change their eating habits and behaviours. Malnutrition may be related to eating

disorders which often involve severe restriction or purging of nutrients. This can result in

poor health and social outcomes, such as reduced fertility and a negative impact on

relationships. The prevalence of eating disorders is difficult to determine due to their

complex nature and inconsistencies in their diagnosis. However it has been estimated that

between 608,000 and 725,000 people in the UK are suffering with an eating disorder6.

The number of hospital admissions across the UK for teenagers with eating disorders has

nearly doubled in the last three years, according to the NHS. They increased from 959 in 13

to 19-year-olds in 2010/11 to 1,815 in 2013/147. Although the numbers are relatively small,

experts say the rate of increase (89%) is mirrored by a larger number of cases that don't go

to hospital7. The Royal College of Psychiatrists attributes much of the increase to social

pressure made worse by online images.

The risk of malnutrition is more commonly associated with those aged 65 or over; one in ten

people over 65 are malnourished or at-risk of malnutrition5.

The causes of malnutrition in the elderly are multifactorial and there are numerous clinical

consequences for this age group. In older adults, changes to digestive capacity, taste, basal

metabolic rate, and feelings of hunger, satiety and thirst can all increase the risk of nutritional

compromise. Age-related chronic neurodegenerative diseases such as dementia,

Parkinson’s disease and strokes can have a particularly significant impact on nutritional

status8.

The Office for National Statistics predicts that the number of adults in the UK aged over 65 is

expected to increase by 50% in the next 20 years to over 16 million9. Therefore more, older

3

people will be affected by malnutrition. The risk of malnutrition increases with age and those

aged over 75 are at highest risk. Furthermore, 14% of older people in sheltered homes are

at high risk of malnutrition10. Other groups at risk include children born prematurely, those

living in deprived circumstances and those suffering from chronic disease with an impact on

nutrition e.g. intestinal disease, cancer and those with eating disorders.

Common risk factors for malnutrition are described in further detail in Table 1. Some of these

are not related to disease and may be preventable.

Risk factors in Table 1 may be more commonly associated with adults however the list also

applies to younger age groups and children who may suffer from specific problems as

outlined above.

Table1: Factors associated with Malnutrition

Medical Factors Lifestyle/Social

Factors

Other Risk

Factors

Risk Factors in

Hospital/Care Homes

Reduced appetite

due to illness/

underlying medical

condition

Dysphagia

(Swallowing

problems due to

poor dentition/loss of

teeth)

Nausea and vomiting

Infections Other

diseases e.g.

Cancer,

Neurological,

Intestinal,

Respiratory or

Endocrine Disease

Ageing process lead to

declining taste

Limited mobility/high

risk of falls due to

reduced bone

synthesis

Poverty

Social isolation

Poor access to shops

Lack of cooking skills

Limited access to

facilities/equipment to

cook

Religious dietary

restriction

Limited mobility or a

lack of knowledge

making it difficult to go

shopping or cook food

at home or go out to

meet other people

further exacerbates

social isolation leading

to malnutrition

Recent discharge from

hospital

Misconception that its

normal to become

thinner as you get older

Lack of

awareness

amongst staff

of identifying

and treating

malnutrition

effectively

Lack of

nutrition

training for

medical staff

so it’s

perceived as

less important

Depression

Recent

bereavement

Dementia

Anxiety

Confusion

Quality assurance of

catering food provision

for patients-how food is

presented, limited food

choices on menu

Missing teeth/poor oral

hygiene

Unable to reach food,

use cutlery, open

packages especially if

they have suffered from

Stroke and are confused

Unpleasant sights, smell

and sounds

Increased nutrient

requirements due to

infection, wound healing

Not taking account of

religious/cultural dietary

needs

Nil by mouth or missing

meals whilst having

tests, altered taste due to

radiotherapy or

chemotherapy

Limited mobility with

hands and feet following

surgery, may require

assistance with feeding

Source: Table modified from: Hickson, M. (2006). Malnutrition and Ageing. Postgraduate Medical Journal. 82,

p.2-8.

4

In addition to these general risk factors for malnutrition, there are some specific conditions

and social factors which carry a significant nutritional burden. Some of these are outlined

below:

Cancer

Patients presenting with cancer can have significant nutritional problems which arise from

not only the disease process but also, the anatomical locality of the cancer and its

treatments. Weight loss is common amongst people with cancer and weight loss or

malnutrition affects up to 85% of cancer patients at some point6,11. Symptoms at

presentation can include weight loss, dysphagia, early satiety, loss of appetite, nausea and

vomiting, all of which can impact negatively on nutritional status. In addition, being

overweight or obese is a risk factor for oesophageal cancer and this may mask the problem

of weight loss in such patients; therefore careful nutritional assessment is important.

Malnutrition is associated with poorer treatment and patient-centred outcomes, however

adequate nutrition can help people with cancer to maintain their weight, maximise outcomes

and improve quality of life7,9,12,13.

Dementia

Patients with dementia are particularly at risk of malnutrition. As dementia progresses,

patients with dementia often experience increased difficulty with eating and drinking, and this

can result in weight loss and poor health outcomes12. The majority of people with dementia

live in the community, with around a third estimated to live in a care home9,13. Studies

reviewed in the report Nutrition and Dementia have shown that up to 45 percent of those

living with dementia experience clinically significant weight loss over one year, and up to half

of people with dementia in care homes have an inadequate food intake10,14. Therefore it is

important to consider nutritional care and support in the community to support the nutritional

status of people with dementia.

Depression

Mental health conditions such as depression and anxiety can contribute to malnutrition11,15.

Depression could act as a powerful risk factor for malnutrition in older people and is the most

common mental health problem in people in Kingston12,16.

Living alone, social isolation and housing

Malnutrition is common in those who may be socially isolated living alone with no support or

limited mobility13,17. Social isolation has been defined as an individual lacking a sense of

belonging, social engagement and quality relationships with others18. Although social

isolation is difficult to measure directly, as the proportion of older people living in the borough

increases, more residents are at risk of becoming socially isolated. Older adults who are

socially isolated also have an increased nutritional risk15,19.

According to POPPI estimates, in 2015 the total population aged over 75 predicted to be

living alone is 5,305. This number is predicted to increase by 53% by 2030 to 2128.

5

Food Poverty

Research evidence shows that malnutrition is common in people from lower socio-economic

groups. Food poverty is associated with a poor diet and is a risk factor for major diseases. It

is estimated that as many as 10 million people in the UK live in poverty, including nearly

three million children16,20. Low income households tend to consume fewer nutrients and

fewer fresh fruit and vegetables than average-income households17,21 and the Fabian

commission on food and poverty suggests that in the UK, household food insecurity arises

from the cost of living rising faster than income 18,22. Due to a lack of official measurement, it

is unclear how many people are affected by household food insecurity in the UK however

there has been an increase in the number of hospital admissions for malnutrition. Data

collected in 2013 show primary and secondary diagnoses of malnutrition (caused by lack of

food or very poor diet) rose from 3,161 in 2008/09 to 5,499 in 2012/1319,23 suggesting

societal factors may be playing a role in increasing malnutrition.

Child poverty is expected to rise to 3.9 million by 2015. A survey carried out by save the

children, ‘Child Poverty in 2012 it shouldn’t happen here’20,24, shows that poverty in the UK

can result in parents cutting back on food so their children don’t go hungry. In 2012, nearly

12% of all dependent children under 20 in Kingston were in relative poverty (living in

households where income is less than 60% of median household income before housing

cost).

Causes and Risk Factors

The causes of malnutrition can be broadly categorised into three groups, however in reality,

the cause is often multi-factorial. Some examples of the causes of malnutrition are outlined

below:

Reduced nutritional intake (e.g. due to low food availability of food, loss of appetite,

problems with eating and drinking, poor access to food (social exclusion, poor

transport, difficulties shopping), poverty, cognitive decline, poor mental wellbeing,

depression, anxiety)

Reduced nutrient absorption (may be caused by disease processes e.g. Crohns,

complications from drug therapy)

Increased requirements (e.g. acute illness/infection, surgery, disease processes e.g.

cancer pr Parkinson’s disease, medical intervention e.g. drains).

In the UK, the most common causes of malnutrition amongst children are medical conditions

such as cystic fibrosis and cerebal palsy that impact nutrient absorption, reduce appetite,

and cause an increase in energy needs21,25. Amongst young children, malnutrition as a result

of inadequate food intake is rare in the UK, although malnutrition may occur if a child is

neglected, living in poverty or being abused. Children might also become malnourished

because they avoid eating due to issues with their body image or have an eating

disorder26,27.

6

For older people or those in care homes or hospitals, who have difficulties with eating and

drinking, inadequate care relating to nutrition and hydration may exacerbate malnutrition.

Common occurrences include8.

A lack of support with feeding

Food left out of reach

Nutritional supplements not given frequently.

There are numerous adverse outcomes of malnutrition on quality of life for both individuals

and their carers. There is a summary of some of the clinical consequences of malnutrition.

Further detail of the clinical effects of malnutrition can be found in Table 2 of Malnutrition

Matters Meeting Quality Standards in Nutritional Care (2010)

The clinical consequences of malnutrition include1,28:

Impaired immune response (and increased vulnerability to disease)

Reduced muscle strength

Impaired wound healing

Prolonged recovery from disease or injury

Loss of temperature regulation

Impaired psychosocial function

Specific nutrient deficiencies

Impaired ability to regulate body electrolytes salt and fluid.

Malnourished individuals, compared to well nourished, individuals have an increased

dependence on both primary and secondary care, including:

Greater healthcare needs in the community (e.g. more care at home, antibiotics)8

More intensive care needs amongst those in nursing home settings

65% more GP visits costing the NHS £1,449 per patient per year29

Increased prescription costs2

Increased (82% more) admissions and re-admissions to hospital8

Increased medical complications (e.g. infections)8

Increased length of stay (30% longer) at hospital8

Increased morbidity30

Increased risk of death30,31

Managing malnutrition

Since malnutrition increases a person’s vulnerability to ill-health, adequate nutrition support

should improve outcomes although in reality the situation is more complex, as are decisions

on the most effective and safe means of providing nutritional support which should

be individually tailored to a person’s needs.

However there is some evidence that improving nutrition, with support from a dietitian, can

help to12:

Prevent health problems

Improve functional status32

Increase quality of life and wellbeing for people living with long-term conditions (such

as such as cancer, chronic obstructive pulmonary disease (COPD) and dementia)

Provide cost savings to the NHS2.

7

Regular screening for nutritional risk with validated screening tools, such as the Malnutrition

Universal Screening Tool (MUST), is recommended by various key groups including the

National Institute for Health and Care Excellence (NICE)1, and the national patient safety

agency; however various care settings are failing to screen patients as recommended5. This

delays the initiation of appropriate care and nutritional support for vulnerable patients and

may lead to further deterioration of those who are already malnourished5.

Malnutrition in those aged 65 and over

Malnutrition is largely a preventable and treatable condition and there is good evidence that

nutritional support in older people can decrease weight loss, improve functional outcomes

(e.g. muscle strength, walking distance, activity levels and mental health) and also improve

clinical outcomes in both community and hospital settings33. In addition, for those people

living in care homes, there is some evidence that appropriate nutritional screening and

support can:

Reduce in hospital admissions

Reduce length of hospital stay (with associated cost savings)12.

Similarly, nutritional support for patients with conditions such as cancer can support

treatment, reduce treatment complications, reduce the length of time in hospital and improve

quality of life.

Managing malnutrition in the community and in care settings could also provide significant

financial benefits. NICE identifies malnutrition as the sixth largest potential source for NHS

savings34 and early identification and treatment of malnutrition in adults could save the NHS

£13 million a year after costs of training and screening1. NICE have also demonstrated that

screening, early intervention and treatment could save £71,800 per 100,000 people35 and

appropriate use of oral nutritional supplements (ONS) has been found to save £849 per

patient based on length of stay in hospital36.

Health and social care organisations in the community are well placed to manage the burden

of cost related to malnutrition37,38. One strategy to achieve this involves enabling older

people to remain in their own home or sheltered accommodation. This includes staff from

health and social care raising self-awareness amongst older people of malnutrition and

hydration.

BAPEN have produced the malnutrition universal screening tool (MUST) to identify and

manage malnutrition in both the acute and community settings. The NICE (2006) CG32

guideline has shown that this will contribute to significant cost savings. The benefits for

investing in prevention and treatment of malnutrition outweigh the cost leading to significant

cost saving opportunities.

The Malnutrition Task force has produced a fact sheet which outlines further costs and

impact of malnutrition.

Evidence highlights the appropriate use of oral nutritional supplements (ONS) is associated

with a reduction of overall hospital readmissions related to malnutrition by 30%.

8

Key Drivers for Improvements to Malnutrition

Malnutrition is recognised as a key public health issue and more work is required to address

it. This includes meeting evidence-based recommendations highlighted in the key policy

guideline documents listed below:

NICE 2006 guidelines. Refreshing the National Public Health outcome framework

2015-2016 domain 4d for improving patient’s experience with hospital food

BAPEN Malnutrition Matters meeting quality care standards in nutritional care

Malnutrition Taskforce to address malnutrition in the community

Managing Adult Malnutrition in the Community pathway

Care Quality Commission (CQC) standards for nutrition

NHS England Commissioning guidance for excellent nutrition and hydration

BAPEN report on cost savings from nutritional interventions

Fabian Policy Report – Hungry for Change

Visit Managing Adult Malnutrition in the Community for more information.

References for Introduction 1 NICE. Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube feeding and Parenteral Nutrition.

Methods, Evidence and Guidance. National Collaborating Centre for Acute Care, London. February 2006 2 Elia, M. The cost of malnutrition in England and potential cost savings from nutritional interventions (full

report). Southampton: Biomedical Research Centre. 2015. 3 BAPEN. Introduction to Malnutrition. 4 Elia M.and Russell C.A. BAPEN. Combating Malnutrition: Recommendations For Action Output of a meeting of

the Advisory Group on Malnutrition 12 June 2008 5 Beating Eating Disorders (BEAT) The Costs of Eating Disorders. Social, Health and Economic Impacts. BEAT

[Internet] 2015 6 Brotherton, A. and Simmonds, N. on behalf of the BAPEN Quality Group. Malnutrition Matters Meeting Quality

Standards in Nutritional Care. Redditch, Worcs. British Association for Parenteral and Enteral Nutrition (BAPEN).

2010. 7 Beating Eating Disorders (BEAT) (2015) Rising Eating Disorder Hospital Admissions – What the Figures Mean. 8 The Malnutrition Taskforce. Malnutrition in Later Life: Prevention and Early Intervention Best Practice Principles

& Implementation Guide. A Local Community Approach. London. Malnutrition Malnutrition Taskforce (2013)

Malnutrition in Later Life: Prevention and Early Intervention Best Practice Principles & Implementation Guide A

Local Community Approach. 9 Age UK. Later Life in the United Kingdom. February 2016. 10 Elia, M. And Russell, C.A. Screening for Malnutrition in Sheltered Housing. (BAPEN). 2009. 11 The British Dietetic Association The Value of Nutritional Care in Helping the NHS to Deliver on the NHS

Outcomes Framework: An assessment of how delivering high quality nutritional care can enhance the quality of

life for people with long-term conditions. 12 Sauer, A.C. and Coble Voss, A. Abbott Nutrition Institute. ‘White Paper: Improving Outcomes with Nutrition in

Patients with Cancer,’ 2012 13 Baldwin, C., Spiro, A., Ahern, R. And Emery, P.W. A Systematic Review and Meta-Analysis Journal of the

National Cancer Institute. Oral Nutritional Interventions in Malnourished Patients with Cancer. 2012

9

14 Alzheimer’s Disease International 2014. Nutrition and Dementia London. Alzheimer’s Disease International. 15 Vfaei, Z., Mokhtari, H., et al. Journal Research Medical Science. Malnutrition is associated with depression in

rural elderly population. 2013. 18; S15-S19. 16 NHS Kingston CCG. Dementia Strategy for Kingston upon Thames 2015-2020. 17 McHugh, J., Lee, O., Aspell, N.L., Brian, A. & Brennan, S. Medline JMIR Research Protocols. A shared

mealtime approach to improving social and nutritional functioning among older adults living alone: study protocol

for a randomized controlled trial. 2015. 4; pg 43. 18 Dury, R. (2014). Social isolation and loneliness in the elderly: An exploration of some of the issues. British

Journal of Community Nursing, 19(3), 125-128. 19 Locher, J. L., Ritchie, C. S., Roth, D. L., Baker, P. S., Bodner, E. V., & Allman, R. M. (2005). Social isolation,

support, and capital and nutritional risk in an older sample: Ethnic and gender differences. Social Science and

Medicine, 60, 747–761. 20 Faculty of Public Health (2015). 21 Public Health England. (2008/2009-2011/12). National Diet and Nutrition Survey: Results from years (-4)

(combined) of the rolling programme (2008/2009-2011/12). Executive Summary. 22 Tait C. On behalf of the FABIAN Society. The final report of the Fabian Commission on Food and Poverty:

Hungry for Change. Online October 2015 23 Parliament website. Publications and Records. 24 Whitman G. On behalf of Save the Children. Child Poverty in 2012: It shouldn’t happen here. Online 2012. 25 NHS Choices Website. Malnutrition Causes. 26 Campbell, K. And Peebles, R. Eating Disorders in Children and Adolescents: State of the Art

Review. American Academy of Paediatrics. 2014. 134; 582. 27 Sahib, A. And Radhi, El. Appropriate care for children with eating disorders and obesity. British Journal of

Nursing. 24; 518-522. 28 Managing Adult Malnutrition in the Community (2012). Including a pathway for the appropriate use of Oral

Nutrition Supplements (2012). Produced by Multi Professional Consensus Panel. 29 The Malnutrition Taskforce. A review and summary of the impact of malnutrition in older people and the

reported costs and benefits of interventions. May 2013. 30 Stratton, R.J., King, C.L., Stroud, M.A et al (2006). Malnutrition Universal Screening Tool predicts mortality and

length of hospital stay in acutely ill elderly. British Journal of Nutrition. 95, pg 325-330. 31 Charlton, K.E., Batterham, M.J., Bowden, S. et al A high prevalence of malnutrition in acute geriatric patients

predicts adverse clinical outcomes and mortality within 12 months. E-Spen Journal. 2013. 8. (3): e120-e125. 32 Cawood, AL. et al Systematic review and Meta-analysis of the effects of high protein and oral nutritional

supplements. Ageing Research Review. 2012; 11 278-296. 33 Gandy, J. (eds). Manual of Dietetic Practice. 5th ed. Oxford. British Dietetic Association 2014. 34 Malnutrition Taskforce. Addressing Malnutrition: Commissioners Mini-Guide. 35 NICE support for commissioners and others using the quality standard on nutrition support in adults November

2012. 36 Elia, M. et al, The cost of disease related malnutrition in the in the UK and economic considerations for the use

of oral nutritional supplements (ONS) in adults, BAPEN, 2005 37 Rebecca, M. (2014). Community Management of Nutrition and Hydration Community Nutrition. Vol 6, p. 11. 38 Carers UK the Voice of UK. Malnutrition and Caring. The hidden cost for families. Nutricia Advanced Medical

Nutrition. 2012.

10

Local Picture

There is a lack of local data of the prevalence of malnutrition in Kingston. However, based

on national prevalence of malnutrition (Table 2), it can be assumed that approximately 3,053

older people (>65 years) are malnourished in Kingston.

The main points are summarised below, for the local data that is available. These are

grouped together into different topics and include accommodation, costs, mental health, life

expectancy, poverty, dementia, cancer and social isolation.

Royal Borough of Kingston (RBK) Sheltered Housing: Malnutrition is common

amongst older tenants in sheltered housing. In Kingston there are 843 sheltered

homes which suggests between 82 and 115 people aged 55+ living in sheltered

homes are at risk of malnutrition (based on national prevalence predicted by

BAPEN). See Table 2

Total Population aged 65 and over requiring Care at Home: Malnutrition is higher

in care settings such as care homes, hospital inpatients and those receiving care at

home. This is influenced by the increased likelihood of patients in these settings

being more accurately monitored and malnutrition recorded more often. The number

of malnourished people in Kingston receiving care at home is 183

Total Population aged 65 and over living in a care home with or without

nursing care: The longer a person is able to remain independent in their own home,

the less likelihood of them becoming malnourished, relying on care homes and

hospitals. The total population aged 65 and over living in a care home, with or without

nursing care is estimated to increase from 776 to 1200 between 2015-2030; an

estimated increase of 54% by 2030 according to POPPI.

Potential Cost for Over 65 year olds admitted to hospital: Following diagnosis of

malnutrition, the incremental six monthly costs to the NHS attributable to malnutrition

was estimated to be £1,003 per patient1. In addition, severely malnourished patients

identified in general practice incur additional health care costs of £1,449 per patient

in the year following diagnosis (mainly incurred through additional GP consultations

and hospital visits37). Put into a local context, with an estimated 3,053 adults over 65

years of age malnourished in Kingston from 2014, this equates to malnutrition-related

healthcare costs of £3,062,159 over six months

Mental health units all admissions: Nationally, it’s estimated there is 19%

prevalence of malnutrition in mental health unit admissions2. In Kingston over 21,000

adults are estimated to have a common mental health disorder (CMD). These figures

could indicate that approximately 20% of this cohort could possibly be at risk of

malnutrition.

Life Expectancy: From 2011-13, life expectancy at 65 years was 19.4 years for

males living in Kingston and 21.7 years for females; above the England averages

11

(male 18.7 years and female 21.1) but only above the London average for males

(male 19.1 years and female 21.9)3. The population of Kingston residents aged 65

and over is projected to increase by 28.7% between 2014-20294.

Malnutrition and Poverty: Deprivation including social, economic and

environmental factors may increase an individual’s risk of developing nutritional

problems such as malnutrition. The 2010 to 2011 Joint Annual Public Health Report

shows that a number of areas in Norbiton, Grove, Canbury, Berrylands, and Tolworth

and Hook Rise are within the most deprived category in Kingston with respect to the

proportion of older people, experiencing income deprivation. See older

people chapter for map index of multiple deprivation 2010 ranking by ward-income

deprivation affecting older people)/. Research evidence suggests that a higher

proportion of the population in deprived areas, are at risk of malnutrition. For

Kingston, this highlights that those adults living in the deprived areas e.g. Norbiton

and Canbury maybe at risk of malnutrition. The Kingston information and advice

Alliance helps to make sure residents over the age of 60 receive their benefits. ‘Stay

Well at Home’ and ‘Help at Home’ services are provided in conjunction with some

local GP practices.

Table 1: Prevalence of Malnutrition in Kingston by Population Group 2013/14

Population Group Kingston

Population Data

Malnutrition

Prevalence

Estimated Number of

Malnourished based on National

prevalence predicted by BAPEN

Population aged 65 years and over 21,808a 14% 3,053.12

RBK Sheltered housing 823b 10-14% 82-115

Total Population aged 65 and over

requiring Care at Home 883c 25% 183

Total Population aged 65 and over

living in a care home with or

without nursing care

776d 30-42% 245-343

Over 65 year olds admitted to

hospital 6,225d 30% 1,868

Mental health units all admissions - 20% -

(a) Source: Office of National Statistics Mid-year Population Estimates: Pivot Table Analysis Tool for the United Kingdom, 2013

and 2014.

(b) Number of Sheltered Home places in Kingston is 832 for adults aged 55+people in Kingston as quoted by Royal Borough of

Kingston Housing Contact Centre and of the 832 sheltered homes, 9 Sheltered home places are vacant. Therefore 823 are

occupied by adults aged 55+

(c) Number of Kingston residents aged 65+ provided home care by social services (excluding private/family care), 2015 quoted

by Strategic Business Team Social Services

(d) POPPI system data for 2015 People aged 65 and over living in a care home with or without nursing by local authority

projected to 2030.

(e) Source quoted by Kingston Hospital Dementia Strategy Group. This is data quoted for the last financial year April 2014 to

March 2015

12

Dementia

In Kingston is it estimated that there are between 1,417 residents over the age of 65 who

have dementia, which equates to 7.28% of the local population over 655. This figure is

projected to rise to 1,594 although this will be a decrease in value as the older population

rises (6.78% of population over 65) by 2021.

Currently, there are more people registered with Kingston GPs (under the responsibility of

Kingston Clinical Commissioning Group) than live in the borough, and for this group the

estimated number of people with dementia in 2015 was between 1,5536 and 1,8747. The

number of people with dementia who are looked after by Kingston GPs is higher because

people from outside Kingston borough are registered with Kingston GPs and this number is

also rising. Furthermore, there are currently 1000 people on the dementia register locally.

In Kingston hospital 48% of inpatients above the age of 75 have confirmed or suspected

diagnosis of Dementia, a cohort of which is more likely to be at risk of malnutrition. As

quoted by the Kingston Hospital Dementia Strategy group from April 2014 to March 2015,

14089 admissions to Kingston hospital were with patients aged over 75. Fifty percent of

these patients suffer Dementia (7,405 adults) and 45% (3332 adults aged over 75) will also

be at risk of malnutrition.

Cancer:

The incidence of Cancer in Kingston is similar to the rest of England (381.9 per 100,000

people)8.Patients presenting with cancer can have significant nutritional problems which

arise from not only the disease process but also, the anatomical locality of the cancer and its

treatments. Weight loss is common amongst people with cancer and weight loss or

malnutrition affects up to 85% of cancer patients at some point9. Malnutrition is associated

with poorer treatment and patient-centred outcomes, however adequate nutrition can help

people with cancer to maintain their weight, maximise outcomes and improve quality of life10,

11.

Living alone, social isolation and housing

Almost 36.4% of Kingston residents aged 65 and over are predicted to be living alone in

Kingston (8,425 people), including 22.9% of those aged 75+ (5,305). Over two–thirds

(67.6%) of those living alone are female. This is projected to rise by 44.9% to 12,208 by

2030. Older people living alone at home may require support from social, housing and

voluntary services. There are a range of health risks associated with living alone; a study by

Kharicha et al12 found in their study that those living alone were more likely to report fair or

poor health, and poor diet was one of the key themes of the study.

Living alone can increase social isolation and impact wellbeing for older people, as housing

under occupancy can impact financial standing and mood, which may also have an effect on

food intake and nutrition.

The majority of older people in Kingston live in homes that are owned by them instead of

social housing.

3.3% of those over 65 (776 residents) are estimated to be living in a care home in

Kingston13. Care home residents have a unique, complex mix of health-care needs.

Dementia, stroke, degenerative neurological conditions, advanced cardio-respiratory

13

disease, cancer and painful arthritis are common conditions, and ones that are often

accompanied by loss of appetite or difficulty with eating and drinking14.

References for Local Picture

1 The Malnutrition Taskforce. A review and summary of the impact of malnutrition in older people and the

reported costs and benefits of interventions. May 2013.

2 Bapen. Nutrition Screening Survey in the UK and Republic of Ireland in 2011.

3 Office of National Statistics, 2015.

4 2014 Round of Demographic Projections- trend based population projections, short term migration scenario,

2015. © GLA 2015 Round Demographic Projections

5 Local Dementia UK statistics (England).

6 Calculation based on target number for Kingston CCG from NHS England, and based on CFASII

7 Calculation based on Alzheimer’s Society Research 2007 which estimates 0.0095% of total population has

dementia

8 Cancer Research UK. Local Cancer Statistics.

9 The British Dietetic Association The Value of Nutritional Care in Helping the NHS to Deliver on the NHS

Outcomes Framework: An assessment of how delivering high quality nutritional care can enhance the quality of

life for people with long-term conditions. October 2013

10 Sauer, A.C. and Coble Voss, A. Abbott Nutrition Institute. ‘White Paper: Improving Outcomes with Nutrition in

Patients with Cancer,’ 2012

11 Baldwin, C., Spiro, A., Ahern, R. And Emery, P.W. A Systematic Review and Meta-Analysis Journal of the

National Cancer Institute. Oral Nutritional Interventions in Malnourished Patients with Cancer. 2012

12 Karicha et al (2007). Health risks appraisal in older people 1: are older people living alone san ‘at risk’ group?

British Journal of General Practice. 57 (537), 271-276.

13 Apetito Value of Meals on Wheels Service 2013. Meeting the Wider Funding Challenge The Real Value of

Meals on Wheels.

14 British Geriatrics Society (2011) Quest for quality an inquiry into the quality of healthcare support for older

people in care homes: a call for leadership, partnership and improvement.

14

What Works

There are numerous guidelines around the treatment and prevention of malnutrition such

as NICE CG32 and The Malnutrition Task force.

These suggest that malnutrition in older people can be prevented by:

Maintaining independence

Reducing social isolation

Ensuring access to food and services

Tackling poverty

Improving quality of life

Holistic multi-disciplinary approach

Raising awareness and training frontline staff.

Improved nutritional care has been identified as having a large potential cost saving to the

NHS. NICE has recognised malnutrition as the sixth largest source for potential NHS

savings.

Preventing malnutrition should be an integral part of preventative health care and located

within the public health agenda. The malnutrition task force offers 5 best practice principles

for tackling malnutrition in the community and care settings1, which are in line with NICE

clinical guidelines. Recommendations from both are summarised below.

Raising awareness among front line staff to support prevention and early treatment of

malnutrition through better education for staff and individuals

Organisations should prioritise malnutrition as part of their care plans and should

include staff training of the importance of adequate nutrition and hydration as well as

coordinated care from a multidisciplinary team.

Multidisciplinary team (MDT): e.g. in and across care homes and hospitals

A joined up multi-disciplinary approach (MDT) ensures there is good communication

between patients and professionals

Setting up a steering committee to oversee and manage malnutrition in both acute

and community settings should be represented by an MDT

MDT including commissioners and providers from health and social care with a

universal attitude is required to tackle and prevent malnutrition.

Identifying malnutrition in the individual using validated screening tools such as the

MUST (Malnutrition Universal Screening Tool) and identifying prevalence within

organisations and the community

Early screening is cost effective compared to treating malnutrition once established

at both national and local level

15

Regular screening and monitoring should take place at GP visits, routine health

checks, vaccinations, routine weights, on admission to care homes, and whenever

there is clinical concern.

Developing personalised and dignified plans of care, treatment, support and

monitoring

In the first instance, it is recommended to treat the underlying condition that may cause

malnutrition. Management options include:

Support with feeding

Addressing social issues

Ensuring ability to shop (physical and financial) and prepare food

Texture modification, dietary advice to maximise nutritional intake (also known as

food first).

Oral and Artificial Nutrition Support (following screening, oral nutrition support

measures such as):

First line approach is dietary advice to optimise oral intake

Food fortification

Snacks

Sip feeds

Artificial feeding depends on clinical judgement such as when nutritional

requirements are less likely to be completely met via oral nutrition support.

Evaluating the impact of the care and support on a patient’s weight, improvements

and outcomes.

Monitoring both the individual (their food intake and weight) as well as the processes

in place to address malnutrition.

Social Interventions

Taking a whole person holistic approach (addressing several of the causes of malnutrition) is

important to managing malnutrition. There are several areas that could be addressed at both

an individual and community level. Examples of these include:

Encouraging eating together in care homes/creating positive dining experience

16

Encouraging increased food intake

Tackling lack of access to food

Tackling difficulties in cooking

Reducing isolation

Preventing ill health

Reducing poverty

Reducing depression

Supporting independence.

Supporting older people to maintain independence is one way to prevent malnutrition.

Community projects can offer improved access to food and additional social value. For

example, The Food Train Dumfries programme in Scotland enables older people to access a

healthy acceptable diet and to remain independent at home whilst reducing social isolation,

thereby tackling other risk factors for malnutrition.

Meals on Wheels Services also encourage people to remain independent and stay in their

own home2. They can aid people with eating regularly, encourage personal contact and

being regularly monitored to ensure care needs are met and their nutrition risk does not

increase.

Care Plans

Local and national guidelines including government bodies listed below summarise the

approaches and recommendations that should be implemented to prevent or treat

malnutrition.

1. BAPEN (2010) Malnutrition Matters Quality Care Standards

2. NICE (2006) guidelines (CG32) on Nutrition Support in Adults Oral Nutrition Support

Enteral Tube Feeding & Parenteral Nutrition

3. The Malnutrition Task Force (2013): A review and summary of the impact of malnutrition

in older people and the reported costs and benefits of interventions

4. Managing Adult Malnutrition in the Community (includes a pathway for the appropriate

use of oral nutritional supplements (ONS))

5. The Malnutrition Task Force (2013). Prevention and Early Intervention of Malnutrition in

Later Life consists of the best practice principles and implementation guide to use for a

local community approach

6. NICE Quality Standard 24 (2012). Meeting Quality Standards For Nutrition Support in

Adults

7. Meeting Nutritional Needs-Essential Outcomes Care Quality Commission (2010)

8. Care Quality Commission Report: Time to Listen Dignity & Nutrition in NHS Hospitals

Inspection Programme (2012)

9. Care Quality Commission Report: Time to Listen Dignity

10. NICE guidance (2006) is guidance document for the care of patients with or at risk of

malnutrition.

17

References from What Works

1 The Malnutrition Taskforce. Malnutrition in Later Life: Prevention and Early Intervention Best Practice Principles

& Implementation Guide. A Local Community Approach. London. Malnutrition Malnutrition Taskforce (2013)

Malnutrition in Later Life: Prevention and Early Intervention Best Practice Principles & Implementation Guide A

Local Community Approach.

2 Apetito Value of Meals on Wheels Service 2013. Meeting the Wider Funding Challenge. The Real Value of

Meals on Wheels.

18

Current Services

The Royal Borough of Kingston and local stakeholders have supported the development of a

new Healthy Weight and Physical Activity Needs Assessment and Strategy 2013-2016. The

action plan outlines key recommendations and objectives. This is for partners to meet

current and future needs, providing a framework to deliver key strategic targets:

Reducing the overall prevalence of obesity in children and adults reversing the tide)

Minimising the current increase in obesity prevalence from Reception Year to Year 6

Ensuring all professionals (both health professionals and non-health professionals)

can access relevant training and support the implementation of clear pathways to

follow for adults and children in Kingston

Ensuring robust surveillance data is available to inform service planning and

commissioning.

Older people with poor mobility are likely to find it difficult to access services to help them

with maintaining adequate nutrition and hydration, therefore older people with limited mobility

may be more vulnerable to malnutrition. This is identified in the strategy as a key barrier for

accessing services. Language could also be a barrier but it is thought that many services are

making good progress at incorporating Kingston Interpreting Service support when

necessary. This includes using local community members to translate and incorporate

English lessons within the service content. Further work is required to see if this need is

already met or, if more support is necessary.

Hospital Screening

To tackle malnutrition, all inpatients at Kingston Hospital are assessed for malnutrition using

the MUST tool. Patients identified at high risk are referred to the ward dietitian and assessed

on an individual basis. Appropriate nutritional intervention is then initiated and monitored. At

discharge, a letter outlining nutrition recommendations with details of any nutritional

supplements is sent to the patient’s GP. The GP will assess the patient and prescribe

nutrition support if appropriate; however this post-discharge care is not standardised across

the borough and is likely to vary from GP to GP.

Community Dietetics

There is no commissioned dietetic domiciliary service in the community or nursing homes

unless the patient is enterally fed (when a patient is fed via a tube into the gastro-intestinal

tract). Patients can be seen by the primary care dietitian however this service is limited to

one clinic a month per surgery. In order to access this service, patients need to be mobile

enough to attend the clinic which may leave vulnerable patients without an accessible

service. Patients can either be referred directly by the GP or as a hospital referral to be

19

actioned post discharge. Hospital in-patients are often not mobile enough post discharge to

attend a service, therefore may not be adequately monitored for nutritional outcomes. Local

commissioners should therefore investigate and consider the size of this gap in service.

Stay Well At Home (Kingston service)

The Stay Well at Home Service includes volunteers supporting recently discharged patients

from hospital in their home. Volunteers visit the clients’ home over a number of weeks

making sure the client has shopping. And that fresh food is available at home.

This service looks for different ways the client can get regular and varied food. This includes:

Most days a week, clients using Wiltshire Farm foods

Twice a week, eating at Raleigh House

Once a week, going to a local pub or cafe.

Dining Companion’s Project (Kingston service)

The Dining Companions scheme started in 2012 offering older patients with practical care,

support and companionship at mealtimes. They recruited 387 Dining Companion Volunteers

including public volunteers, non-clinical staff and community groups. This frees up nursing

staff time to focus on patients with more complex feeding requirements.

Dining Companion scheme encourage older patients to eat well and independently at their

highest level of functioning. The scheme has reached 301 volunteers (two volunteers per

mealtime on each ward, seven days a week). More than 50 members of non-clinical

Kingston Hospital Foundation Trust staff since 2012 have been trained as Dining

Companions.

Although these services are specifically focusing on malnutrition, the following services

target families that could potentially be at risk of malnutrition.

Healthy Start Project

Healthy Start is a national programme that targets teenage and low income pregnant

women, and young families. The scheme includes food vouchers and vitamin tablets for

pregnant women. Healthy Start is embedded into midwifery service delivery and is regularly

discussed at strategic meetings that feed into the Health and Wellbeing Board (via the

Residents Health Care Services Committee). This includes the Maternal Obesity Action

Group, the Infant Feeding Partnership, and the Maternity Services Liaison Committee.

Cook and Eat Programmes in Children Centres

Most of the children centres in Kingston upon Thames run Cook and Eat programmes for

families with children aged zero to five to address fussy eating and support families to cook

healthy meals for their children.

20

Eating disorders in Young People

Increasing access to Psychological Therapies (IAPT) welcome referrals for mild to moderate

eating, that does not, require a specialist service. Referrals can be made in a variety of

ways, including self-referral or referral via the GP, community mental health team or other

health professionals. In severe cases, or where more specialist input is required, referrals

must be made to the South West London and St George’s Eating Disorder Service. Kingston

Hospital Dietetics team will routinely review any patients with a diagnosed eating disorder

who is admitted to the hospital. There is currently no specialist eating disorder service at

Kingston Hospital; however patients can be referred for specialist support. On discharge,

patients are referred back into community services where applicable.

Cook and Eat Programmes for adults

Cook and Eat programmes for adults aim to promote a healthy diet and healthy weight by

providing participants with the confidence and skills to cook and consume a healthier diet.

They are provided at a variety of local community settings. Programmes are not targeted at

individuals suffering from malnutrition, but can form part of the prevention agenda,

empowering participants to confidently cook and eat healthily. Examples of cook and eat

programmes relevant to malnutrition include:

Cook and Eat for adults who are homeless, recovering from drug or alcohol addiction

at Joel Night Shelter Accommodation

Cook and Eat for adults delivered in 2013 accessing Food Bank. Food banks are

charities that provide a minimum of three days emergency food and support to

people experiencing crisis in the UK

Cook and Eat for adults recovering from poor mental health.

The five Cook and Eat programmes in Kingston in 2014-15 have reached a total of 94

people. Participants on all of the programmes have reported improvements in a range of

dietary behaviours and knowledge including improved understanding of food labels and

ingredients.

21

Community Voice

The consequences of malnutrition can impact a patient’s ability to access care, for instance

attending a GP appointment. In addition, malnutrition can have significant social

consequences for the affected individual and their family. Carers UK, a national charity,

highlight that1:

60% of carers worry about the nutrition of the person they care for

One in six carers are looking after someone at real risk of malnutrition but do not

have nutritional support of any kind

55% of carers look after older people on nutritional supplements

16% of the adults that carers care for are underweight with a small appetite.

There has been no consultation specifically about malnutrition with older people locally in

Kingston. It’s recommended that this work takes place, to find out about local services,

perceived need and any other relevant contributions. National evidence from the Malnutrition

Taskforce UK where there has been consultation in 2013 with older people has found:

Engagement with older people on the issue of malnutrition requires avoiding the term

‘malnutrition’ as it’s perceived negatively and is viewed as a sign of poverty and

neglect

The word ‘malnutrition’ should be avoided when communicating with public and

instead terms such as undernourished or underweight should be used instead

Language is important to establishing accurate community voice

Older people prefer positive messages about the effects of malnutrition such as

“Eating and drinking enough is important to maintain your health and independence”

For identifying malnutrition they prefer messages such as “They have lost weight,

they look thin or they have a poor appetite”

Older people felt it is really important to dispel the myth that unintentional weight loss

is a normal part of ageing

It will also be vital to establish reasons behind malnutrition.

A survey carried out by ICM on behalf of Age UK; ‘Cut Backs Survey (2009) in Later

Life’2 showed:

22

22% (3 million people) of people aged 60+ in UK (2009) skipped meals to cut back

on food costs

42% (5.8 million people) of people aged 60+ in UK (2009) agreed they struggle to

afford essential items e.g. food, gas, electricity

Findings from the Review of Kingston Sheltered Housing Report highlighted that even those

that have had recent improvements to housing, often fail basic mobility requirements, such

as lifts to upper floors. This may limit older peoples’ ability to go out this has potential to

further increase social isolation and limit access to nutrition as people may find it difficult to

get out into their local community.

References for Community Voice

1 Carers UK (2012). Malnutrition and Caring. The Hidden Cost For Families. Trowbridge. Nutricia.

2 Age UK. Later Life in the United Kingdom. February 2016.

23

Recommendations

Recommendations for local mapping

Improve surveillance to ensure a clearer picture of local need is available.

Surveillance and analysis of malnutrition should identify any gaps in services for

malnutrition which can then be addressed through the action plan. A Malnutrition

needs assessment has been agreed to take place for residents in Kingston upon

Thames

Map the use of the MUST tool for screening or other identification tools used in care

settings in the borough

Review the actions taken as a result of malnutrition screening to establish pathways

of care currently in place and determine if key guidelines and CQC standards are met

Collection of local prevalence data on malnutrition (e.g. BMI and/or MUST score at

various points of care) in community and hospital/care settings

Identify if older people settings have their own local nutrition treatment care plans in

place and if they are adhering to these nutrition care plans

Ensure local strategy for healthy weight includes malnutrition and fits with national

policy

Complete a full Malnutrition needs assessment consulting local stakeholders and

patient including mapping current services available relating to malnutrition across

the life course.

Recommendations for planning of service provision

Review dietetic capacity within GP practices to assess if the current level of one clinic

per month per practice is enough to meet the needs of Kingston patients

Use dietetic expertise to review the use of oral nutritional supplementation (ONS) in

Kingston including tackling gaps between prescriptions and ensuring compliance with

protocols. The financial benefits of having a community dietitian have been explored

by the London Procurement Programme, which reported that appropriate ONS

prescriptions could save 15% on ONS expenditure over 2 years

Explore wider determinants of malnutrition such as housing to identify local need

24

Improve accessibility of services. This may include geographical location of services

but also linking with other services, including adult social care and also influencing

planning processes and transport links

Recommendations for service provision/commissioners

Develop a Community follow up protocol upon discharge of patients identified as

malnourished in hospitals in Kingston

Considering commissioning a community Dietitian for domiciliary dietetic visits for

malnourished patients in the community with the aim of reduce patients coming into

hospital as malnourished. Currently there is a service gap for community/nursing

home patients who are malnourished but unable to attend a dietetic appointment at

the GP surgery

Support the dietetic business case for oncology dietitian to increase capacity for

nutritional support for patients with caner

Encourage routine use of the MUST tool screening of individuals in care settings in

the community to identify malnutrition e.g. upon registration with GP, home visit on

admission to care home or hospital. Other screening opportunities include contact

with community pharmacist or District Nurse. Sheltered homes to identify and

manage malnutrition

Ensure Health and social care includes malnutrition in all care pathways for an older

person’s care. Ensuring good communication so older people receive oral nutritional

supplements appropriately and there are no gaps between prescriptions

Identify nutrition training needs amongst front line staff across health, social and

voluntary sector involved with older peoples care in relation to malnutrition

Support care homes in meeting CQC standards with appropriate training as required

Review the need to provide wider prevention programmes such as targeted Cook

and Eat courses

Review if all providers of meals within lunch clubs and day centres for older people

are now adhering to the nutrition standards set for older people.

25

Glossary:

NICE: National Institute for Health and Care Excellence

BAPEN: British Association for Parenteral Enteral Nutrition

GLA: Greater London Authority; The Greater London Authority (GLA) was established by the

GLA Act 1999. GLA staff is appointed by the Head of Paid Service, the GLA’s most senior

official, and serve both the Mayor and the London Assembly.

HLE: Healthy life expectancy (HLE); also called disability adjusted life expectancy,

represents the average number of years that a person can expect to live in full health. This

measure of full health is based on contemporary mortality rates and the prevalence of self-

reported good health. The prevalence of good health is derived from responses to a survey

question on general health.

Multidisciplinary Team (MDT): is a group of health care workers who are members of

different disciplines (professions e.g. Psychiatrists, Social Workers, etc.), each providing

specific services to the patient

MUST: Malnutrition Universal Screening Tool; The ‘MUST’ is a five-step screening tool to

identify adults, who are malnourished, at risk of malnutrition (undernutrition), or obese. It also

includes management guidelines which can be used to develop a care plan.

ONS: Oral Nutritional Supplements

CQC: Care Quality Commission; The CQC are the independent regulator of health and

social care in England. The CQC monitor, inspect and regulate services to make sure they

meet fundamental standards of quality and safety.

Dementia: Dementia is a syndrome resulting from a change in brain tissue causing a loss of

intellectual function and is characterised by a progressive decline in memory, reasoning,

communication skills and gradual loss of skills required for carrying out everyday activities1

(Thomas, B. Manual of Dietetic Practice. British Dietetic Association. 3rd edn. pg

566.Oxford: Blackwell Science Publishing; 2001). Individuals may also develop behavioural

and psychological symptoms such as depression, psychosis, aggression and wandering.

26

Other Needs Assessments

Healthy Weight and Physical Activity Needs Assessment and Strategy 2013-2016

Useful Links

BAPEN Malnutrition Self-Screening Tool

British Dietetic Association Food Facts

NHS Choices Malnutrition Pages: Treatment

NHS Choices Dehydration

NICE: Diet Nutrition and Obesity

Help and Information

NHS Choices: Malnutrition pages for information on malnutrition; overview, causes

and treatment

Malnutrition Taskforce Website

Malnutrition Taskforce: List of Key references on malnutrition