BAPEN Publishes Results of Biggest Malnutrition Survey Ever Undertaken
Results show highest prevalence of ‘malnutrition’ in the winter months (34% of UK adults admitted to hospital) and people in England at greater risk than those in Scotland
Today BAPEN publishes five Nutrition Screening Week (NSW) Reports which cover the UK as a whole and its four nations; England, Northern Ireland, Scotland and Wales. The Reports contain the amalgamated data of its four Nutrition Screening Weeks which took place over a five year period between 2007 and 2011, each in a different season of the year. The Nutrition Screening Week surveys involved a total of 661 hospital centres and data on 34,699 patients admitted to hospitals across the UK and is the biggest survey into the prevalence of ‘malnutrition’* ever conducted. Whilst the results of the individual surveys have been announced annually, these new Reports highlight seasonal and country specific trends and chart the changes made to the practice of nutritional screening and provision of nutritional care in UK hospitals.
Importantly the report highlights that during the five year period there was some evidence of improvements throughout the UK in terms of awareness of ‘malnutrition’, in nutritional screening practice and in the organisation of nutrition support services. There were significant increases in the proportion of hospitals with a nutrition screening policy, undertaking audits of nutritional screening and recording patients’ weights and heights on admission. However, despite NICE Guidelines, there was little improvement in the proportion of hospitals with access to a Nutrition Support Team (NST), which are required to manage complex nutrition cases. Encouragingly the ‘Malnutrition Universal Screening Tool’ (‘MUST’) was the most commonly used screening tool being used by 82% of centres by 2011.
The overall mean prevalence of ‘malnutrition’ in patients admitted to hospital was 29% but there was variation between the nations, with the highest in England (30%) and lowest in Scotland (24%). Most were at high risk. Explanations for the national differences are complex and need to take into account the different healthcare systems that operate in the devolved nations such as; the distribution of care between hospitals and the community; the number of beds per capita of population, which is greater for Scotland than England; the differences in screening policies, screening practice, audits, standards and inspections. In addition, national differences in age, gender, BMI distribution and types of diseases also affect the individual populations.
There were marked differences between certain characteristics of adults admitted to hospital and the general population of the UK. The mean age of adults admitted to hospital during the five year period was around 15 years higher, while the mean BMI slightly lower than the general population. More people admitted to hospital were underweight (<20 kg/m2) or severely obese (≥40 kg/m2) than in the general population.
The overall prevalence of ‘malnutrition’ on admission to hospitals varied significantly between seasons: 28% in autumn and summer, 34% in winter, and 25% in spring. The higher prevalence in winter can be related to a number of factors: greater social isolation in the cold weather which may result in reluctance of people to go out shopping or visit their GP to have their health problems attended to; more severe accidents on icy surfaces; more severe hypothermia, and more prolonged and severe chest infections. The well-known effects of malnutrition causing weakness, lethargy, impaired temperature regulation and immunosuppression could predispose to such problems during cold weather.
The Scottish report shows that there have been significant changes and improvements in awareness of ‘malnutrition’, as well as in nutritional screening practice and in the organisation of nutrition support services. The improvements in awareness and performance indicators related to the management of malnutrition coincided with the implementation of and inspections concerning NHS QIS Standards on Food, Fluid and Nutritional Care. In addition, unlike the UK as a whole and other nations of the UK, there was improvement in the proportion of hospitals with access to a NST which was available in over 7/10 centres in 2011..
The results for Wales suggest that over the five year period in which the NSW surveys were conducted some improvements in awareness about ‘malnutrition’, nutritional screening and in the operational infrastructure of nutrition support services have been made. There was a higher use of local screening tools rather than the ‘Malnutrition Universal Screening Tool’ (‘MUST’) and access to NSTs was variable over the study period with some centres reporting no access indicating more improvement is needed in this respect.
Unfortunately, limited data were available from only three of the surveys for Northern Ireland. Results suggest that there is substantial room for improvement in a number of aspects of nutritional care and operational infrastructure. While nutritional screening was linked to care plans in almost all hospitals in the two surveys when this question was asked, this was not routinely followed through into discharge planning. And although all centres participating in the surveys had access to dietetic services, overall only 38% had access to a nutrition support team.
In England during the five year period there was evidence of improvements in awareness of ‘malnutrition’, in nutritional screening practice and in the organisation of nutrition support services. There were also significant increases in the proportion of hospitals with a nutrition screening policy and those undertaking audit of nutritional screening but there was little improvement in routine screening. However, most hospitals used ‘MUST’ and nutritional screening was linked to care plans in almost all hospitals in all 4 surveys. Despite this there was no significant improvement in the inclusion of nutritional information in discharge communication over the survey period.
“The results of the NSW Surveys reflect the changes and improvements seen during 2007-2011 but there is still room for much more to be done. We hope that the recent publication of the NICE Quality Standard and a focus on nutritional screening in all nations of the UK will results in greater prioritisation and further improvements in the provision of good nutritional care.” Marinos Elia, BAPEN Lead, Nutrition Screening Week.
Age related Data
Overall the prevalence of ‘malnutrition’ was about 33% higher in those aged 65 years or older than those less than 65 years old. However, when ‘malnutrition’ was divided into 3 categories (<40 years, 40-59 years and ≥60 years) the prevalence was higher in younger and older adults (27%, 23% and 32% respectively). Reasons for this included a higher prevalence of ‘malnutrition’ in those aged <40 years and ≥60years than in those in the intermediary age group within a variety of different diagnostic categories (e.g. respiratory, cardiovascular, genito-urinary and musculoskeletal conditions).
(NB the majority of patients admitted to hospital are aged 65 years and over)
There was a consistently higher prevalence of ‘malnutrition’ in women than men by 3-6% (mean 4%). The difference was more marked in those aged 65 years or older than those less than 65 years old.
Source of Admission
In all the surveys, the majority of patients were admitted from their own homes and at least 1 in 4 were at risk of ‘malnutrition’ on admission. Overall, half of the patients admitted from care homes were also at risk but these accounted for the smallest proportion of admissions.
The NSW surveys in all the nations have re-emphasised the widespread nature of ‘malnutrition’. They have also confirmed that the prevalence of ‘malnutrition’ varies according to many factors including: the source of admission; the type of ward (being higher in care for the elderly and oncology wards than orthopaedic wards); disease category (being higher in gastrointestinal and respiratory diseases than musculoskeletal and cardiovascular diseases), and presence of cancer (being higher in those with cancer than those without).
“Since the NSW surveys involved nutritional screening on admission to hospital, mainly of patients from their own homes, the data reflect problems that arose in the community which could be identified prior to admission. Policies aiming to prevent the problems from developing or to initiate treatment at an early stage need to focus on the community and to integrate services between care settings. Hospitals have an important role to play in identifying ‘malnutrition’ and communicating the results to the community so that treatment initiated for inpatients or outpatients can be continued in the community.” Christine Russell, BAPEN Lead, Nutrition Screening Week.
The NSW surveys show that some changes and improvements have been reported over the five year period in which the surveys were undertaken. However, there is room for further improvement within hospitals particularly in relation to discharge communication about ‘malnutrition’ which was found to be patchily carried out, and the formation of more NSTs. The NSW surveys also indicated that the proportion of underweight individuals admitted to hospital (BMI < 20 kg/m2) or severely obese (≥40 kg/m2) is in contrast to the general population. Preventing the development of underweight and obesity in free living individuals could have a substantial effect on reducing hospital admissions and costs.
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*. ‘Malnutrition’ – refers to those at medium + high risk according to ‘MUST’ (http://www.bapen.org.uk/screening-for-malnutrition/must/introducing-must)
Notes for Editors
The four surveys and audits on nutritional screening were undertaken by BAPEN during 2007 - 2011 in collaboration with the British Dietetic Association and the Royal College of Nursing and with support from the Welsh Government, the Scottish Government, the Chief Nursing Officers for England and Northern Ireland and the Patient Safety, Domain 5, NHS England (who have taken on responsibilities of the former National Patient Safety Agency).
The current 5 reports are based on the amalgamated data from the four surveys. A copy of these Reports can be downloaded at:
‘Malnutrition’, in terms of undernourishment, is both a cause and consequence of disease in adults and children. It is common and affects over 3 million people in the UK with associated health costs exceeding £13 billion annually.1 It is often unrecognised and therefore untreated, yet it has a substantial impact on health and disease in all community care settings and hospitals.1,2
The benefits of improving nutritional care and providing adequate and appropriate hydration are immense, especially for those with long term conditions and problems such as stroke, pressure ulcers or falls. The evidence shows clearly that if nutritional needs are ignored health outcomes are worse and meta-analyses of trials suggest that provision of nutritional supplements to malnourished patients reduces complications such as infections and wound breakdown by 70% and mortality by 40%.2
Better nutrition and hydration care for individuals at risk can result in substantial cost savings to the NHS1 with even a saving of only 1% of the annual health care cost of ‘malnutrition’, amounting to £130 million annually.1 Recent guidance from the NICE (NICE CG32 and NICE standard 24) identifies better nutritional care as a large potential source of cost savings to the NHS3,4 and CCGs should use the NICE data to calculate potential cost savings for their local Trusts. Nutrition and hydration were also identified in the eight ‘high impact’ actions5 and have been a key focus in the delivery of harm free care in the Department of Health QIPP Safe Care Work Stream programme, recognition that improvements in nutrition and hydration care will have substantial positive impact on all 4 key harms.
- Elia M, Russell CA (eds). Combating malnutrition; Recommendations for Action. A report from the Advisory Group on Malnutrition, led by BAPEN. Redditch: BAPEN, 2009.
- Stratton RJ, Green C and Elia M. Disease related malnutrition; an evidence-based approach to treatment. Oxford:CABI, 2003.
- NICE. Cost saving guidance. 2012. (Accessed November 18, 2012, at www.nice.org.uk/usingguidance/benefitsofimplementation/costsavingguidance.jsp.)
- NHS Institute for Innovation and Improvement. High Impact Actions for Nursing and Midwifery. 2009. (Accessed January 30, 2010, at www.institute.nhs.uk/images//stories/Building_Capability/HIA/NHSI%20High%20Impact%20Actions.pdf)
- NICE Quality Standard, QS24 (Nutrition in Adults) - Issued: November 2012 (http://guidance.nice.org.uk/QS24)
Releases for Scotland and Wales are available via the links below: