Long term conditions: Malnutrition - risks and prevention in vulnerable groups

Malnutrition is a surprisingly common problem, but one that practice nurses are in an ideal position to identify, especially in elderly patients or those with a pre-existing condition such as COPD

Malnutrition in the community is a major problem within the NHS and its identification and treatment has the potential for making huge savings not only in economic terms but also in quality of life and improvement in patient outcomes. Patients with existing conditions and elderly patients are particularly at risk of malnutrition. This article outlines the facts about malnutrition and how to tackle it, with a focus on undernutrition in vulnerable COPD patients.

MALNUTRITION IN THE UK

Malnutrition is a state of under- or over-nutrition where there is a lack of protein, energy and other nutrients leading to significant adverse effects on tissue, body composition, physiological function or clinical outcome.

Malnutrition is, and continues to be, a serious problem in the UK. According to the British Dietetic Association (BDA),¹ there are more than 3 million people in the UK who are at risk of malnutrition; the vast majority, about 93%, of these are living in the community setting, with 5% in residential care and 2% in hospital. Malnutrition has been clearly linked with greater use of healthcare with an estimated 65% more GP visits, 82% more hospital admissions and 30% longer hospital stay. Economically speaking, the burden of this is enormous: the health and social care costs in the UK directly associated with malnutrition come to more than £13 billion per annum (based on 2007 prices). In addition, a 2011 BAPEN survey of 10,000 patients found that more than one in three admitted to hospital in the UK is at risk of malnutrition.²

Older people are particularly at risk of malnutrition and its complications, for a variety of reasons. The BDA¹ reports that an estimated one million older people in the United Kingdom eat less than one meal a day. This can become a vicious cycle as not eating well in older age affects mood and can influence appetite, which in turn, affects nutrient intake. People are significantly at risk of becoming malnourished if they have eaten very little or nothing for more than 5 days and/or this pattern is likely to continue.

Causes of malnutrition are very varied and may result from social, psychological or medical causes. Some examples that are likely to occur in the community setting, as opposed to hospitalised patients, are shown in Box 1.

Malnutrition leads to a lack of strength or energy, such that even doing simple everyday activities is hard. Some of the effects and consequences of malnutrition are shown in Box 2.

Identifying patients at risk

At a time when so much focus is on preventing and managing obesity, poor nutrition can be overlooked, ironically even in those patients who are obese. Sudden rapid weight loss or an inadequate intake of protein and vitamins and minerals is as much a problem for obese patients as those who are underweight. However, the classic view of malnutrition as a patient who appears thin and frail needs to be extended to detect malnutrition in patients who are apparently overweight. Those at risk can be of any age, although elderly people and those with chronic health conditions are particularly at risk. With patients who you suspect are malnourished (or likely to become malnourished), it is essential to identify the problem early so that support can be provided.

In the community setting as well as the hospital setting, screening can help to stem the problems of malnutrition, resulting in improved patient wellbeing and reduced hospital admissions. Ideally this will involve routine screening using a validated nutritional screening tool. A number of screening tools have been developed to help identify whether a patient is at risk of malnutrition. A screening tool should help establish reliable pathways of care for patients with malnutrition or at risk of malnutrition.

One such tool is 'Malnutrition Universal Screening Tool' or 'MUST' (www.bapen.org.uk), which is recommended by NICE. The 'MUST' is a quick and simple tool which has been validated for use in primary care and involves 3 steps: assessment of body mass index (BMI), recent changes in weight and likely nutritional intake over the coming 5 days. Although 'MUST' primarily screens for malnutrition it also highlights those patients with an excessive BMI. However, BMI alone is not an indicator of good nutritional status. Table 1 shows BMI classifications and actions.

In addition to anthropometric measurements to assess BMI, a number of questions to help understand a patient's food intake and current nutritional status can help to identify patients at risk of malnutrition and to identify the appropriate course of action for the patient. Suggested questions include:

1. How is your appetite?

2. Are you managing to eat as well as you usually do?

3. Have you noticed any changes in your weight? Are clothes and jewellery becoming looser, have friends/family made comments?

4. Have you noticed any other changes to your body shape? Any changes to arms and legs, muscle strength?

5. Do you have any concerns about your food intake and diet?

FOCUS ON COPD

While COPD is primarily a pulmonary disease, characterised by airflow limitation that is not fully reversible, it also has significant extrapulmonary effects, which may contribute to disease severity in some patients. Airflow limitation is usually progressive, and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, most notably found in cigarette smoke. However, COPD also has a number of other systemic effects, including weight loss, nutritional abnormalities and loss of function in skeletal muscle.³

It is now recognised that nutrition has an important role in the management of patients with COPD. Good nutrition is important in COPD to help to combat some of the comorbidities, which fluctuate and progress throughout the course of the disease.

Many patients with COPD are either underweight or overweight and this influences their prognosis. Symptoms of being short of breath can affect appetite and ability to eat, leading to a reduced nutritional intake and potential weight loss but, conversely, breathlessness can also limit exercise as physical activity is difficult, leading to weight gain if appetite is not adversely affected.

Malnutrition and COPD

Malnutrition is a significant problem in patients with COPD, however it often goes undetected and consequently is often untreated. Research shows that up to 45% of outpatients and 60% of inpatients with COPD are at risk of malnutrition.⁴ Patients with COPD who are at risk of malnutrition, as with all patients with malnutrition, are more likely to be admitted to hospital and experience a longer hospital stay, have earlier readmission rates and often have a poorer prognosis than those patients who are not at risk of malnutrition.

Nutritional screening

It is important to regularly monitor the nutritional status of patients with COPD. Again, the MUST tool has been shown independently to identify those patients with COPD who are likely to go on to have a poor clinical outcome. Poor clinical outcome can result in greater hospital re-admission rates, length of hospital stay and mortality. Clearly identifying malnutrition early in this group is essential in terms of economic and quality of life costs.

If you identify that a patient is at risk of malnutrition, there may be a nutritional management care pathway, but in the absence of this, referral to a dietician is necessary for appropriate nutritional care.

Nutritional Guidelines for COPD have now been released from the Southampton COPD Group, designed to raise the awareness of nutrition with respiratory health professionals. The guidelines (sponsored by an educational grant from Nutricia) provide a simple tool to aid first line nutritional management of this patient group and improve the nutritional status of COPD patients.

Resources, including patient information and Powerpoint presentations developed by the expert group are available from website www.copdeducation.org.uk

Conclusion

Malnutrition is a major problem in the UK and some groups of patients and elderly people are particularly at risk. However, increased awareness of the ways to identify patients at risk, and strategies to prevent malnutrition in high risk groups can potentially lead to huge relief in the financial and personal burden from malnutrition.

REFERENCES

1. WHO/IDF Saint Vincent Declaration Working Group. Diabetes Mellitus in Europe: a 1. British Dietetic Association (2012) Mind the Hunger Gap Campaign http://www.mindthehungergap.com/about/facts.html (Accessed March 2012)

2. BAPEN (2011) Nutrition Screening Survey http://www.bapen.org.uk/pdfs/nsw/nsw10/nsw10-report.pdf (Accessed March 2012)

3. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011. Available from: http://www.goldcopd.org/.

4. COPD Education (2012) Latest Guidelines http://www.copdeducation.org.uk/Category-284/Nutrition (accessed March 2012)

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