The malnourishment malaise

This surprisingly common problem is under-recognised, and often untreated

It’s hard to believe that with our standard of living at an all-time high in the UK, people can suffer from malnourishment. Yet, with an ageing population and more screening in hospitals and care homes, the problem of malnutrition has become a more obvious issue. ‘It’s estimated that three million people are affected by malnutrition,’ says Rhonda Smith, a spokesperson for the British Association of Parenteral and Enteral Nutrition (BAPEN). ‘Of those, one in three of them will be people admitted to hospital and one in four will be entering care homes.’
When people imagine the effects of malnutrition, they may think of famine-ravaged people from developing countries. The reality is more complex. In fact, it’s actually possible to be malnourished and obese. ‘Obese people may be eating foods which are energy dense but not nutrient dense, so they could be lacking in some vitamins and minerals,’ says Eileen Steinbock, chairman of Food Counts, a specialist group for dietitians within the British Dietetic Association (BDA).

Symptoms of malnutrition
The signs to look out for are:

• Unexplained or rapid weight loss – even without weighing the person, it may be apparent to family and friends because clothes look too big or jewellery such as wedding rings look loose.

• Tiredness and decreased mobility because muscles waste away.

• Wounds taking longer to heal and being more prone to pressure sores.

• Difficulty staying warm.

• Slow immune response – you pick up infections easily and take longer to recover.

• Low libido and fertility problems.

Diagnosis is a ‘MUST’
Many cases of malnutrition are picked up when you’re admitted to hospital or a care home. ‘It’s not currently compulsory in England to screen all patients for malnutrition – some hospitals do it automatically, some don’t,’ says Smith. Malnutrition and its associated problems cost the NHS £13 billion year, and BAPEN would like to see England follow the example of Scotland, and have mandatory malnutrition testing on admission to hospital. They have created a specific screening method known as MUST (Malnutrition Universal Screening Tool), which is a set of three questions that a dietician or health professional can ask to establish whether a patient is malnourished. These are:
1 Do they have a low BMI? Check the patient’s body mass index (BMI) by taking their weight and height measurements.

2 Has the patient lost weight unintentionally in the last 3-6 months?

3 Do they have any underlying health problems that may cause weight loss and malnourishment? Have they eaten anything in the last five days?
‘Scores for each question are added together to calculate each patient’s overall risk of malnutrition,’ says Smith. Once your score is known, a suitable care plan can be arranged.

What causes malnutrition?

Vegetarianism and veganism

‘A poor vegetarian or vegan diet may lack enough protein or vitamin B12 which are usually found in animal products, so it’s important to eat enough protein to replace the meat or fish,’ says Steinbock. This can be found in lentils, pulses (beans), seeds and nuts. ‘Vegan diets will lack vitamin B12 and this can be provided by a supplement.’

Eating the wrong foods

‘When people choose to avoid groups of foods, they could be missing nutrients,’ says Steinbock. This could be the case with people who follow diets that omit certain foods, anorexia and bulimia sufferers, and even obese people. ‘No single food provides everything needed for a balanced diet, the key is to eat a variety of different foods every day,’ adds Steinbock. The French have a good rule – eat at least three different coloured foods on your plate at each meal.

Alcoholism

‘In extreme cases, people may be drinking alcohol rather than eating food, so this would lead to malnutrition,’ says Steinbock. ‘It should be remembered alcohol provides calories so may mask some of the effects of a poor diet.’

Being old

Malnutrition among the elderly is quite common. ‘Older people are more likely to feel socially isolated and depressed, especially if recently bereaved,’ says Smith. ‘This may mean they lack appetite or motivation to cook.’ Chewing and swallowing can be a problem, especially if they have bad teeth or dentures. ‘Mobility problems may mean older people can’t get to the shops as much as they should, and could also make handling heavy pans and kitchen equipment difficult,’ adds Smith.

Illness

Certain illnesses can affect how the body absorbs nutrients, meaning you could become malnourished. Crohn’s disease and ulcerative colitis are inflammatory bowel conditions that impair the absorption of nutrients. ‘Coeliac disease is a classic condition that can lead to malnutrition, but once it’s identified and you’re put on a gluten-free diet, this can be managed,’ says Steinbock. ‘After a stroke, people may be left with dysphagia (a swallowing problem). Other conditions like multiple sclerosis and Parkinson’s disease may make chewing or swallowing difficult, so less is eaten.’

Being in hospital

BAPEN estimates one in three people admitted to hospital every year are already malnourished. Age Concern’s ‘Hungry to be heard’ is a campaign to tackle the problem. They claim hospitals sometimes give the wrong type of food to a patient, don’t help them cut up food and don’t encourage those with smaller appetites to eat. Age Concern are now working with the NHS to improve awareness of the problem among staff.

Low income

People on very low incomes often have poor diets. This may be because of a lack of awareness of healthy diets, or difficulty getting hold of ingredients. ‘A healthy diet doesn’t have to be expensive,’ says Steinbock. ‘Pick two-for-one offers on fruit and veg at supermarkets and buy in season.’ Bulking up meat dishes with extra veg or pulses (such as adding lentils to a pasta sauce) will keep costs down.

Treatment

This depends on the severity of the malnutrition. Once it has been identified using the MUST screening method, a care plan will be put in place and you will be monitored. You may need additional high calorie food supplements to help you put on weight quickly. If you’re severely malnourished, there’s also artificial support in the form of enteral (food is passed into your stomach through a tube) or parenteral (sterile nutrient-rich liquid is fed directly into your blood stream) feeding. ‘For less serious cases, ensure you eat little and often and keep your fluid intake up,’ says Smith. Eat a healthy diet containing the five main food groups; carbohydrates, fruit and veg, protein, dairy and fats.
The key to preventing malnutrition is to help raise awareness. ‘Malnutrition builds up over time,’ says Smith. ‘It can take up to a year before symptoms become clear.’ So if you, a friend or family member falls into one of the at-risk categories, be particularly vigilant.

What about me? I’m not malnourished!
‘Everywhere I look there’s advice on how to lose weight safely and properly, but nothing on how to put on weight. I’m naturally skinny, but still healthy and would like to put on weight. What’s the healthiest way?’ Melanie, Nottingham
Nutritionist Carina Norris says: ‘You’re right that just as it’s unhealthy to be overweight, it’s not a good idea to be underweight. When you need to put on weight healthily, you have to know the foods that are high in calories and energy, yet won’t increase your risk of heart disease and type 2 diabetes. The wrong way to gain weight is by fillingup on fatty foods like pizzas dripping with cheese, fatty meats, chips, ice cream, cakes and chocolate – a surefire way to clogged arteries. Instead, add foods to your diet that are calorific because they’re rich in the healthy unsaturated fats that are good for your health. Try snacking on unsalted nuts and seeds, adding avocado to salads, and drizzling olive oil (or stronger tasting oils such as sesame or walnut oil) over salads and steamed veg. Also try eating more oily fish – good for protein, and rich in heart-healthy omega-3 essential fatty acids. You can also increase your food intake by slipping in healthy snacks, and increasing your meal portion sizes.’

Words: Hannah Fox