Why Food Matters

for Older People

Rhonda SmithMinerva Health & Care Communications Ltd

Why Food Matters

for Older People

• Food as ‘glue’ - vital for society, for all

• Food & drink

– Preventative: access, services, support

– Supports well-being/activities of daily living

– Essential part of care

– Improves health outcomes

• Perfect focus for ‘joining up’ community, care, housing & health

• Variable awareness, policy, practice & resources across the UK

• Some progress in policy, professions and wider public

• However ….. malnutrition is common in the older population

Malnutrition: under-nutritionthere’s a lot of it across the UK

3 million in the community at any one time*

Incidence of low body weight (BMI < 20)

>5% of the ‘healthy’ UK adult population over 65 yrs

>10% of the ‘unwell’

higher for those suffering from cancer, lung disease,

GI problems, neurological and psychiatric illness

* The ‘MUST’ Report, BAPEN 2003

Malnutrition: under-nutritionthere’s a lot of it across the UK

3 million in the community at any one time*

Incidence of low body weight (BMI < 20)

>5% of the ‘healthy’ UK adult population over 65 yrs

>10% of the ‘unwell’

higher for those suffering from cancer, lung disease,

GI problems, neurological and psychiatric illness

Malnutrition in hospital and care

– tip of the under-nutrition iceberg!

* The ‘MUST’ Report, BAPEN 2003

Hospitals – malnutrition on admission

Proportion at risk of malnutrition

28% 6% medium risk; 22% high risk (2008)

Data on individual patients across the UK

• 9722 individual patients

• 9460 with ‘MUST’ scores

• 9338 with ‘MUST’ scores in patients 18 y and over

Number of Hospitals

• 175

BAPEN Nutrition Screening Week Report 2008

Care Homes – malnutrition on admission

Proportion at risk of malnutrition

~30% 10% medium risk; 20% high risk (2008)

Data on individual residents across the UK

• 1610 individual residents

• 1610 with ‘MUST’ scores

• 1610 with ‘MUST’ scores in residents 18 y & over

Number of Care Homes

• 173

BAPEN Nutrition Screening Week Report 2008

• More people live in sheltered housing

than in care homes (~750,000)

• More individuals with malnutrition in

sheltered housing than in hospitals

Sheltered Housing (England)

Proportion at risk of malnutrition

10-15% half/half medium/high

Screening for Malnutrition in Sheltered Housing BAPEN 2009

* If height, weight or weight loss cannot be established, use documented or recalled values (if considered reliable). When measured or recalled height cannot be

obtained, use knee height as surrogate measure.

If neither can be calculated, obtain an overall impression of malnutrition risk (low, medium, high) using the following:

(i)Clinical impression (very thin, thin, average, overweight)

(ii)aClothes and/or jewellery have become loose fitting

(ii)bHistory of decreased food intake, loss of appetite or dysphagia up to 3-6 months

(iii)cDisease (underlying cause) and psychosocial/physical disabilities likely to cause weight loss

† Involves treatment of underlying condition, and help with food choice and eating when necessary (also applies to other categories).

OVERALL RISK OF UNDERNUTRITION *

(i) BMI (kg/m2)

0 = >20.0

1 = 18.5-20.0

2 = <18.5

(ii) Weight loss in 3-6 months

0 = <5%

1 = 5-10%

2 = >10%

(iii) Acute disease effect

Add a score of 2 if there

has been or is likely to be

no or very little nutritional

intake for >5 days

0

LOW

ROUTINE CLINICAL

CARE†Repeat screening

Hospital – every week

Care homes – every month

Community – every year for special

groups, e.g. those >75y

1

MEDIUM

OBSERVE

Hospital - document dietary and fluid

intake for 3 days

Care homes (as for hospital)

Community - Repeat screening, e.g.

from <1mo to >6 mo (with dietary

advice if necessary)

2 or more

HIGH

TREAT

Hospital – refer to dietitian or implement

local policies. Generally food first followed

by food fortification and supplements

Care homes (as for hospital)

Community (as for hospital)

Add scores

The Malnutrition Universal Screening Tool ‘MUST’

Malnutrition: under-nutritionMultiple adverse effects on the individual

Immunity - low WBCs,

CMI, globulin & SIR

HypothermiaImpaired gut

integrity and

immunity

Renal function - loss of

ability to excrete

Na & H2O

Decreased Cardiac output

Ventilation - loss of

muscle & hypoxic

responses

Psychology –

depression & apathy

Anorexia

Micronutrient deficiency

Loss of strength

Liver fatty change,

functional decline

necrosis, fibrosis

Impaired wound

healing

Slide courtesy of Dr Mike Stroud, Chair, BAPEN

Prevalence & consequences

of malnutrition in the UK

SECONDARY CARE

complications

length of stay

readmissions

mortality

CARE HOMES

30-42% of recently

admitted residents

HOSPITAL

28% of admissions

PRIMARY CARE

hospital

dependency

GP visits

prescription costs

SHELTERED HOUSING

10-14% of tenants

HOME

General population (adults)

BMI <20kg/m2 : 5%

BMI <18.5kg/m2 : 1.8%

Elderly: 14%

Prevalence of

malnutrition

Source: BAPEN Toolkit, 2010

The Malnutrition Carousel

15-60% of patients

admitted to hospital

are already malnourished

Up to 70% of patients

discharged from hospital

weigh less than on admission

More GP visits

Home Hospital

More hospital

admissions

Longer stay

More support

post- discharge

Professor Marinos Elia, Chair, Malnutrition Action Group (MAG), BAPEN

BAPEN – UK Cost of Malnutrition – health & social care

2006 - £7.3 billion 2009 - £13 billion

Obesity 2007 - £4.7 billion

Treating Malnutrition Works – 1

COPD Elderly HIV / AIDS Liver

disease

Surgery

improved respiratory function

increased hand-grip strength

increased walking distance

reduced number of falls

increased activities of daily living and mobility

improved immune function

increased well being

improved cognitive function

immune function changes

lower incidence of severe infections

improved liver function

greater wound healing

less fatigue

less loss of muscle strength

Treating Malnutrition Works – 2

0 10 20 30 40 500 5 10 15 20 25 30

30 RCT, n = 3258

RR 0.59 (CI 0.48 to 0.72) 10 RCT, n = 494;

RR 0.29 (CI 0.18 to 0.47)

Decreased complications % Decreased mortality %

Controls Controls

Treatment Treatment

Southampton meta-analysis of oral and

enteral feeding in malnourished patients

Slides courtesy of Dr Mike Stroud, BAPEN/Southampton

hospital

community

Distribution of under-nutrition

in the UK

hospital

community

Proportion of illness spent in hospital

from onset to complete recovery

Adapted from slides provided by Prof Elia/Dr Stroud, BAPEN

Malnutrition in the Community

• Prevent in first place

• Identify where there is risk or where it

exists already

• Inform/support individuals/families

• Provide resources to implement action

• Ensure information flow between settings

– GP, hospital, sheltered housing, care

• Greatest risk at transition

Progress – Scotland leading the way

• 2003 screening on admission to hospital mandatory (e.g. BAPEN’s ‘MUST’)

• Training – development & use of e-learning

• NHS Scotland – Nutrition Quality standard

• Nutrition Ambassadors – outreach to care and community (2 year funding ends)

• Nutrition Clinical Network for Hospital staff (future?)

• Community meals provision valued – protected?

Progress – across the UK

• NICE: nutrition support for adults: hospital, care & community - implementation slow

• Nutrition summit – Nutrition Action Plan & Governance Board – findings ignored

• BAPEN – Nutrition Screening Weeks: size of problem

• Age UK – Hungry to be Heard: public feedback

• RCN – Essence of Care: nutrition/hydration benchmark

• Quality Board – value not simply cost: focus on outcomes

• Nutritional care – 4th most cost effective initiative (NICE)

• Chief Nurses – nutrition ‘high impact action’

• Guidance galore: care catering, nutrition standards, diets, meal planning for care homes

Reaching the ‘Tipping Point’

• NHS England: Care Quality Commission

Hospitals, care homes and all clinics – legal requirement

Outcome 5: Food and drink should meet

people’s individual dietary requirements

• Health & Well-being Boards: Public Health responsibility – prevention/promotion – all programmes

• Commissioners – GPs & other clinical stakeholders:

nutrition as cross-cutting theme – across all care and disease pathways

• NICE – nutrition as a Quality Standard

Where does nutrition fit in the quality improvement framework.....Slide courtesy of DH/Ailsa Brotherton

The Big BAPEN Push

• Westminster All Party Parliamentary

Group – Nutrition & Hydration

• Focused Clinical Guidance

• Partnership working across sectors and

professions – can’t do it alone

• Collaboration across all UK nations

• Europe has woken up to malnutrition

Europe & Malnutrition

• Council of Europe – human rights focus

• Studies across Europe reveal same prevalence rates as UK in hospital & care

• European Nutrition Day in hospitals – record how much food is eaten not given

• Annual prize for European country tackling malnutrition most effectively – won by BAPEN 2008!

• Malnutrition included alongside obesity in health declarations

• EC - ENVI Committee upcoming debate on screening & mandatory action

Continuum of Nutritional Care

Prevent – Identify – Treat – Support

from Food to Specialist Feeding

Community - Care - Hospital

Making the ‘Business Case’

for nutritional care together

and working together are the keys

to preventing & effectively treating

avoidable malnutrition

Thank you for this

opportunity

www.bapen.org.uk