Malnutrition - The Public Health Issue Overshadowed by Obesity - Joanne Casey IPH, Open, Conference, Belfast, Northern, Ireland, Dublin, Titanic, October, 2014, Health Public

1. Malnutrition:
The Public Health Issue
overshadowed by Obesity
A multidisciplinary initiative to close the
gap on malnutrition

2. Malnutrition:
A global Public Health Issue
Malnutrition is a condition that occurs when a person’s diet does not contain
the right amount of nourishment.
It means ‘poor nutrition’ and can refer to:
• under nutrition – when you don’t get enough nutrients
• over nutrition – when you get more nutrients than you need
Promoting Good Nutrition Strategy 2011 DHSSPSNI
The prevalence of malnutrition of patient admitted to hospital in NI is 29%

3. Causes of Malnutrition
Cause Example
Increased nutritional requirements • Infection
• Involuntary movement
• Trauma
• Major surgery
Reduced nutritional intake • Dysphagia
• Pain
Increased nutritional losses • Malabsorption
• Diarrhoea
• Wound exudate
Those at greater risk of malnutrition include people:
• Over the age of 65 years
• With long-term conditions e.g. kidney disease, chronic lung disease
• With chronic progressive conditions e.g. dementia, cancer
• Who abuse drugs or alcohol
• Who use multiple prescriptions and over-the-counter medications (Polypharmacy)

4. Causes of malnutrition:
Additional risk factors
Risk factor Example
Poverty • Inability to access good food
• Inability to afford good food
Psychosocial factors • Isolation / Loneliness
• Confusion
• Depression
• Anxiety
• Dementia
• Bereavement
Mobility • Poor mobility
• Disability
• Poor transport links
• Difficulty accessing local
shops
Functional constraints • Inability to prepare food
• Poor dental / oral health
• Sensory disability
• Difficulty using food
containers
• Difficulty reading food
labels

5. Clinical effects of Malnutrition
Immunity – Increased risk
of infection
Decreased Cardiac output
Hypothermia
Impaired gut
integrity and
immunity
Renal function - loss of
ability to excrete
Na & H2O
Ventilation - loss of
muscle & hypoxic
responses
Psychology –
depression & apathy
Anorexia
Loss of strength
liver fatty change,
functional decline
necrosis, fibrosis
Impaired wound
healing
Adapted from Nutrition Now Workshop

6. Consequences of Malnutrition
• Increased risk of
– Pressure sores
– Respiratory infections
– Falls
– Complications following surgery
– Poor quality of life
• Tripled risk of mortality in older patients in hospital
• More than quadrupled risk of mortality 6 months after
discharge

7. Treatment

8. Financial implication
• £13 billion in the UK in 2007
• More than DOUBLE the amount spent on obesity and overweight
• Clinical costs include
– 65% more GP visits
– 82% more hospital admissions
– 30% longer hospital stay
14
12
10
8
6
4
2
0
NHS expendature on Obesity and Malnutrition 2007
Obesity Malnutrition
£ billion
• Better nutritional care 3rd largest potential cost-saving to NHS

10. Oral Nutrition
£12
£10
£8
£6
£4
£2
£0
2009
2010
2011
UK regions: spend per head
2009
2010
2011
2009/10
2010/11
2011/12
2009
2010
2011
England Wales Scotland NI

11. Oral Nutritional Supplements
In certain conditions some foods have characteristics of drugs and the Advisory
Committee on Borderline Substances (ACBS) advises as to the circumstances in
which such substances may be regarded as drugs
Oral nutrition supplements are prescribable products that can be used as a
simple, effective method of providing nutrition support to people who are
malnourished.

12. Joint Initiative
Delivery of enhanced outcomes for patients, ensuring appropriate use of Oral
nutritional Supplements & management of malnutrition which has delivered
prescribing efficiencies which can be redirected into patient care
MEDICINES MANAGEMENT
DIETITIAN INITIATIVE
The Public
Health Agency
Health & Social Care
Board

13. Target Population
Targeted sample of GP practices:
0.5- 1.94 % of patients registered with these GP practices are on ONS
• People who are prescribed oral nutritional supplements who are
not under the care of trust dietitians
Intervention
• Offered a individual Nutritional Assessment to targeted
individuals
• Provide nutritional advice , education and care plan
• Training

14. Food First
The ‘food first’ approach is the term used for general dietary guidance to improve food
intake. It includes strategies such as:
• Increasing food frequency
• Modifying food intake
• Fortifying foods
to increase the consumption of energy and nutrient-dense foods and nourishing drinks.
Strategy Example
Increasing food frequency Little and often, small frequent meals:
3 small nourishing meals and 2-3 nourishing snacks daily
Modifying food intake Swap :
• 1 pint of semi skimmed milk to full cream milk for an extra 100kcals
• Low fat margarine to butter for an extra 50kcals per slice of buttered bread
• Light / diet yoghurt to rich creamy yoghurt for extra 100kcals per pot
Fortifying foods Extra 100-150kcals:
2 teaspoons jam / honey
Matchbox size grated cheese
Tablespoon butter / margarine
Tablespoon double cream
Extra 150-200kcals
1 Tablespoon chocolate spread
1 Tablespoon peanut butter
1 Tablespoon mayonnaise
1 Tablespoon desiccated coconut

15. Measurable Outcomes
Quality
■ 72 practices complete
■ 1605 patients assessed
■ ‘Food first’ where appropriate
Patient Experience
Questionnaire:
■ 92% of patients reported
comparable or improved
wellbeing following appointment
with the dietitian
GP Questionnaire:
■ 94% GPs very satisfied with
communication with the practice
before the initiative and what
the initiative entails
Efficiency
£ 1,008,565
annual efficiency to date in
2014
Safety
87% patients with MUST ≥2
had stable or increased BMI @
8/52
94% patients maintained or
increased BMI 8/52 after ONS
stopped
Patient perception of ONS
GP Comment:
“A very worthwhile project undertaken with little or no disturbance in the practice. The admin
was well organised and the expertise of the dietitian was very appreciated.”