For Malnutrition Awareness Week 2021, we’re exploring why malnutrition remains under recognised and the problems this can cause. There are resources available to help healthcare professionals and the general public recognise malnutrition which we’ll discuss in this blog.
The under-recognition of malnutrition
In the UK it is estimated that 1.3 million older adults (>65 years) have, or are at risk of, malnutrition with the majority living in the community¹. Malnutrition is often referred to as the silent epidemic. Obesity occupies a greater presence in public health campaigns and the media, despite malnutrition costing the NHS over three times as much as obesity (£19.6 billion in 2011-2012 for malnutrition versus £6.1 billion on obesity-related health conditions in 2014-2015)²,³.
Despite the increasing prevalence of malnutrition, which Age UK forecast will continue to get worse as a result of the pandemic, it continues to be under-recognised⁴.
Malnutrition prevalence varies depending on the healthcare setting². At hospital admission, it’s estimated that 33.6% of older adults are malnourished². Untreated malnutrition is associated with increased morbidity and mortality which places a significant burden on our healthcare system⁵. There are several factors which may contribute to the lack of recognition of malnutrition. Research by the malnutrition task force (MTF) identified that only half of healthcare professionals (HCPs) (51%) regarded malnutrition as a priority and 54% of HCPs were not aware of services in place to tackle malnutrition⁶. This highlights that HCP training in the identification, treatment and consequences of malnutrition needs to improve, giving it the priority it deserves.
Primary care offers an ideal opportunity for detecting patients with or at risk of malnutrition, yet 71.5% of medical students reported having less than two hours of teaching on nutrition⁷. Lack of training and awareness together with other factors means, malnutrition remains poorly recognised within the primary care setting. This has been exacerbated by the pandemic due to HCPs having less face-to-face contact with patients and vulnerable adults having to isolate, resulting in undetected weight loss⁴.
Older adults' self-perception of body weight and nutritional status can also make it difficult for malnutrition to be identified and treated. A recent study found a lack of agreement between self-perceived nutritional status and objective nutritional status among a group of 197 older adult inpatients⁸. Effective treatment for malnutrition requires a multidisciplinary approach which is patient centred, starting with effective screening and assessment. If individuals do not perceive themselves to be at risk and are unaware of the consequences of malnutrition, they are unlikely to raise this as an issue with their healthcare professional or be less motivated to make necessary dietary changes, hence patient education is also key to the success of malnutrition recognition and treatment ⁸.
Recognising malnutrition before it’s too late
We can all help to raise awareness and tackle preventable malnutrition. HCPs need to educate relatives, carers, and patients to spot the early signs of malnutrition. Symptoms to look out for include⁴:
- Unintentional weight loss; loose fitting clothes or rings.
- Loss of interest in food
- Change in appetite
- Difficulties accessing and preparing food
If any of these symptoms are suspected, encourage the individual to seek advice from their GP.
There are several nutritional screening tools which HCPs can use to identify a person’s risk of malnutrition. The most frequently used screening tool in both acute and community settings is the ‘Malnutrition Universal Screening Tool’ (MUST)⁹. This is a validated screening tool which uses height, current weight, and unintentional weight loss over the past 3-6 months to assess an individual's risk of malnutrition. A limitation of this screening tool is the need for objective and accurate anthropometric measurements.
The good news is that nutritional screening did not stop throughout the pandemic. Remote and self-screening tools were developed which don’t require anthropometric measurements and can be completed by either a patient or carer remotely. Examples of these include:
- The patient's association nutrition checklist (PANC)¹ ⁰
- Simplified nutritional appetite questionnaire (SNAQ)¹¹
- The malnutrition screening tool (MST)¹²
These simplified nutritional screening tools can play an important role in the identification of malnutrition going forward. We have written a helpful article outlining how to access and use these tools here.
The British Association for Parenteral and Enteral Nutrition (BAPEN) provide a easy to use version of ‘MUST’ which is a web-based self-screening tool, helping adults in the community identify their own risk of malnutrition. Individuals identified as being at risk of malnutrition can download a dietary factsheet on how to increase nutritional intake until they are reviewed by their GP or dietitian. Providing the individual has access to the internet and weighing scales, the tool is useful in identification of risk should dietetic appointments be delayed for example, secondary to COVID-19 service disruption. Further information can be found here.
The global leadership initiative on malnutrition (GLIM)
Malnutrition is a global concern, however there is yet to be a consensus on how it is diagnosed. The global leadership initiative on malnutrition is focused on achieving a global consensus on the diagnostic criteria for malnutrition in adults across all clinical settings¹³.
A leadership committee was created with representatives from several global clinical nutrition societies including the European Society for Clinical Nutrition and Metabolism (ESPEN) and the American Society for Parenteral and Enteral Nutrition (ASPEN)¹³.
The committee agreed on a criterion which involves identifying the risk of malnutrition (using any validated screening tool) before grading its severity as either moderate or severe (depending on weight loss percentage, body mass index (BMI), muscle mass and age)¹³.
The aim is to collate data using the selected criteria to enable the comparison of malnutrition prevalence, interventions, and outcomes globally. Going forward, these observations will be used to support the development of global standards of care¹³.
In a post COVID-19 era where face-to-face contact with HCPs is limited, it’s important to educate others and increase awareness of the health risks associated with malnutrition. HCPs can signpost older adults and their carers to remote nutritional screening tools with the aim of effectively identifying risk of malnutrition and introducing timely interventions.
- Stratton R, Smith T, Gabe S. Managing malnutrition to improve lives and save money. 2018;(October):1–16.
- The British Association of Parenteral and Enteral Nutrition (BAPEN). The cost of malnutrition in England and potential cost savings from nutritional interventions. 2015. [Internet]. Available from: https://www.bapen.org.uk/pdfs/economic-report-full.pdf
- Public Health England. Health matters: obesity and the food environment. 2017. [Internet]. Available from: https://www.gov.uk/government/publications/health-matters-obesity-and-the-food-environment/health-matters-obesity-and-the-food-environment--2
- Age UK. Sounding the alarm about the rising risk of malnutrition among older people during lock down. 2021. [Internet]. Available from: https://www.ageuk.org.uk/latest-press/articles/2020/05/sounding-the-alarm-about-the-rising-risk-of-malnutrition-among-older-people-during-lock-down
- Volkert D, Beck A, Cederholm T, et al. Management of Malnutrition in Older Patients-Current Approaches, Evidence and Open Questions. Journal of Clinical Medicine. 2019;8(7):974. Available from: doi:10.3390/jcm8070974
- Malnutrition in England factsheet [Internet]. Malnutrition Task Force. 2019 [cited 6 October 2021]. Available from: https://www.malnutritiontaskforce.org.uk/resources/malnutrition-england-factsheet
- Macaninch E, Buckner L, Amin P, et al. Time for nutrition in medical education. BMJ Nutrition, Prevention & Health. 2020. [Internet]. Available from: doi: 10.1136/bmjnph-2019-000049
- Lueg G, Wirth R, Kwiatkowski J, et al. Low Self-Perception of Malnutrition in Older Hospitalized Patients. Clinical Interventions in Aging. 2020;15:2219-2226. Available from: doi:10.2147/CIA.S278578
- The British Association of Parenteral and Enteral Nutrition (BAPEN). Introducing Must. 2016. [Internet]. Available from: https://www.bapen.org.uk/screening-and-must/must/introducing-must
- Patients Association Nutrition Checklist [Internet]. The Patients Association. [cited 6 October 2021]. Available from: https://www.patients-association.org.uk/patients-association-nutrition-checklist-toolkit
- Cuto O, Structure F. The Simplified Nutritional Appetite Questionnaire (SNAQ) as a Screening Tool for Risk of Malnutrition: Optimal Cuto ff , Factor Structure, and Validation in Healthy Community-Dwelling Older Adults. :1–17.
- Di Bella A, Croisier E, Blake C, Pelecanos A, Bauer J, Brown T. Assessing the Concurrent Validity and Interrater Reliability of Patient-Led Screening Using the Malnutrition Screening Tool in the Ambulatory Cancer Care Outpatient Setting. J Acad Nutr Diet [Internet]. 2020;120(7):1210–5. Available from: https://doi.org/10.1016/j.jand.2019.10.015
- Cederholm T, Jensen G, Correia M, Gonzalez M, Fukushima R, Higashiguchi T, et al. GLIM Core Leadership Committee, GLIM Working Group. GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community. Journal of Cachexia Sarcopenia and Muscle. 2019;10(1):207-217. Available from: doi: 10.1002/jcsm.12383. PMID: 30920778; PMCID: PMC6438340.