Undernourishment has a wide range of effects on health. The Health and Social Care Act means patients must be protected from the risks of inadequate nutrition
Rick Wilson, RD, BSc, is director of nutrition and dietetics, King’s College Hospital Foundation Trust, London.
Wilson R (2010) Embracing the opportunity to make sustainable improvements to nutritional care in all settings. Nursing Times; 106: 27, 12-14.
The enactment of the Health and Social Care Act 2008 represents a watershed moment in the history of the delivery of high quality nutritional care. The problem of undernutrition has been an intractable issue in health and social care for decades.
This new act comes at the same time as a range of new initiatives, such as the high impact actions for nursing and midwifery, which include an action to stop inappropriate weight loss and dehydration in NHS care.
Poor nutritional care equals poor quality care; it is an expensive waste of resources that the NHS can ill afford as we meet the challenge of delivering comprehensive healthcare in this financial climate.
Keywords: Nutrition, Undernutrition, Malnutrition
- This article has been double-blind peer reviewed
- Nutritional care is a vital component of all nursing care.
- Improving patients’ nutrition and hydration has been identified as a high impact action for nurses and midwives.
- Undernutrition has a negative impact on wound healing and combatting infection.
- Obese people can also become undernourished.
- Nurses should use the term “eating for health” rather than “healthy eating”.
The Health and Social Care Act 2008 came into force on 1 April 2010 and was a watershed moment for those wishing to improve nutritional care across the care sector in England. It includes regulation 14, which focuses on protecting patients from the risks of inadequate nutrition and dehydration (Office of Public Sector Information, 2009) (see Box 1).
The term “regulated activity” covers all settings where health and social care is delivered, including people’s homes. The first part of the act brings into being the body responsible for monitoring and enforcing compliance with the law, the Care Quality Commission, which provides further guidance on what it expects to see as evidence of good practice in its document on essential standards of quality and safety (Care Quality Commission, 2009).
Other activities are also being implemented or planned, such as the eight high impact actions for nursing and midwifery, which include an action on “keeping nourished - getting better”. This aims to stop inappropriate weight loss and dehydration in the health service (NHS Institute for Innovation and Improvement, 2009).
In January 2010, Healthcare Quality Improvement Partnership (HQIP) invited tenders for a one year project to develop a national audit of the Essence of Care benchmark on food and nutrition (NHS Modernisation Agency, 2003). The aim is to begin this work in September 2010, which will include residents in social care settings and NHS inpatients and provide a plan for a national audit of food and nutrition in health and social care settings.
In addition, the Department of Health published a progress report on the nutrition action plan (Nutrition Action Plan Delivery Board, 2010) and the government’s response to it (DH, 2010). The latter made a number of undertakings, including:
- Working with stakeholders to ensure health and social care staff have access to good practice guidance and other tools;
- Supporting and enabling action to deliver high quality nutritional care by skilled staff working in an integrated way across health and social care;
- Taking forward action to improve how information is used and presented as part of a strong evidence base to support policy development and assess progress on implementation.
- Much activity is focused on improving nutrition, and the challenge for nurses is to capitalise on this opportunity in the face of an unprecedented squeeze on resources.
Box 1. The Health and Social Care Act - meeting nutritional needs
Regulation 14 stipulates that:
“Where food and hydration are provided to service users as a component of the carrying on of the regulated activity, the registered person must ensure that service users are protected from the risks of inadequate nutrition and dehydration, by means of the provision of:
- A choice of suitable and nutritious food and hydration, in sufficient quantities to meet service users’ needs;
- Food and hydration that meet any reasonable requirements arising from a service user’s religious or cultural background; and
- Support, where necessary, for the purposes of enabling service users to eat and drink sufficient amounts for their needs.
For the purposes of this regulation, ‘food and hydration’ includes, where applicable, parenteral nutrition and the administration of dietary supplements where prescribed.”
Source: Office of Public Sector Information (2009)
The problem of undernutrition
Around seven million people in the UK depend to some extent on others to meet their food and fluid needs (Elia and Russell, 2009). As there is a broad spectrum of need, this may include help with shopping or cooking, meals on wheels or total dependence on artificial nutrition.
Around three million are at risk of malnutrition. Some 28-40% of hospital inpatients, 30-40% of those living in care homes, around 14% of those living in sheltered accommodation and an estimated 10% of vulnerable people living in their own homes are at risk (British Association of Parenteral and Enteral Nutrition, 2009; National Institute for Health and Clinical Excellence, 2006; Stratton et al, 2003).
Undernourishment has a wide range of effects on health and wellbeing, including poor wound healing, depression, pressure ulcers, unintentional weight loss, infection and general malaise. All systems of the human body are affected by lack of food and water. Adults lose approximately three million cells every second, which must all be replaced; nutrients from food are the basic raw materials needed for this (Spalding et al, 2005), so lack of food and water affects all systems of the human body.
The National Patient Safety Agency (2009a) noted inadequate hydration as a common problem in hospitals. Dehydration increases length of stay and is linked to a number of serious conditions, such as coronary heart disease (CHD) and stroke. In one study adequate hydration reduced the risk of CHD by 46% in men and 59% in women; in addition dehydration increased two fold the risk of mortality of patients admitted to hospital with a stroke (Royal College of Nursing et al, 2007).
All this has been shown to have serious consequences, as malnourished people have greater healthcare needs, use primary care services more and are admitted to hospital more frequently than those who are adequately nourished (Stratton and Elia, 2007). When in hospital, malnutrition increases complications, length of stay and readmission rates (Hickson et al, 2004). It presents significant costs to the healthcare system, estimated at £13bn a year (BAPEN, 2009). As the population ages and economic pressures on the healthcare system increase, we must ensure nutritional care optimises health and does not compromise it.
The NHS must generate £15-20bn of savings between now and 2014 (DH, 2009). To deliver healthcare of the same quality and quantity we must make each pound go further. Allowing malnutrition to occur and consume resources unnecessarily is foolish and indefensible.
Obesity and nutrition
Malnutrition can mean under or overnutrition and society faces both problems, in the form of an obesity epidemic and an unacceptably high number of people suffering from lack of proper nourishment.
It is worth noting that people who are obese can also be undernourished. An obese hospital patient is just as vulnerable to the consequences of undernutrition as those of normal weight, as obese people cannot live on their fat alone. Energy stored as fat requires protein, carbohydrate, vitamins and minerals for it to be successfully metabolised. A starved person who is obese loses critical amounts of muscle mass before losing significant amounts of fat. It is with this in mind that the Nutrition Action Plan Delivery Board (2010) recommended the term “healthy eating” is replaced by “eating for health”. In common speech, the term “healthy eating” focuses on reduced energy intake and this is not appropriate for people at risk of undernutrition.
Ensuring people have adequate amounts of food and fluid would seem to be a simple matter and it is surprising that we continue to wrestle with this problem.
Nutrition is a relatively new science and it had a “golden age” during the 1920s and 1930s. Advances in chemistry and medicine helped us to understand the composition of food, that is, the constituent elements of proteins, fats and carbohydrates and the requirements for human health. We began to understand what vitamins were - the very word was only coined by the Polish biochemist Casimir Funk in 1912 (Bender, 2003).
At that time we were particularly concerned with inadequate nutrition, especially among the poor. At the end of the 19th century this was adversely affecting the health of so many poor people that an interdepartmental government report was commissioned to investigate the issue.
By the 1950s, a nation exhausted by war and austerity was tired of the nutrition message, as people associated it with the rationing system and being told what they could and could not eat. At the same time pharmaceutical development was taking its first strides into the modern health economy. Pharmaceutical solutions to the nation’s health problems were very much in tune with the “white heat of technology” mindset of the early decades of the NHS - “a pill for every ill”. As a result nutrition fell from the curriculum of the healthcare professions.
Wanless (2004) and Marmot (2010) have shown that we cannot continue along this path. Even if there was a pill for every ill, we could not afford it. Our efforts must go into delivering a National Health Service and we need to shift the focus away from treating illness towards preventing it and maintaining good health. The delivery of high quality nutritional care is the foundation of health.
High quality care
The nutritional value of food not eaten is nil. Ensuring that patients and service users consume adequate amounts of food and fluid is labour intensive, time consuming and a hallmark of quality care. The delivery of high quality nutritional care is a multiprofessional, multiagency challenge that no single profession can take on alone. This was illustrated in the DH and Nutrition Summit Stakeholder Group’s (2007) joint nutrition action plan, to which 28 professional bodies, patient groups, government and non-government bodies contributed.
The Council of Europe (2003) passed a resolution recognising this and made the provision of good nutritional care a human rights issue. The resolution made more than 100 recommendations for action, which have been distilled into the 10 Key Characteristics of Good Nutritional Care in Hospitals (Council of Europe Alliance, 2009). The wording has since been updated to include all care settings (Nutrition Action Plan Delivery Board, 2010) (see Box 2). The NPSA (2009b) coordinated a series of factsheets providing practical guidance on how these characteristics can be delivered.
Box 2. The 10 key characteristics of good nutritional care
- Food service and nutritional care are delivered safely.
- An environment conducive to people enjoying their meals and being able to safely consume food and drinks is maintained (in hospitals this is known as “protected mealtimes”).
- The care provider supports a multidisciplinary approach to nutritional care and valuing the contribution of all staff, people using the service, carers and volunteers working in partnership.
- Care provider to include specific guidance on food and beverage services and nutrition/hydration care in its service delivery and accountability arrangements.
- Everyone entering care services is screened to identify those who are malnourished or at risk of becoming malnourished.
- Facilities and services are designed to be flexible and centred on the needs of the people using them.
- Everyone using care services has a personal care/support plan and, where possible, has personal input to identify their nutritional care and fluid needs, and how they are to be met.
- All staff/volunteers have the appropriate skills and competencies needed to ensure that the nutritional and fluid needs of people using care services are met. All staff/volunteers receive regular training on nutritional care and management.
- People using care services are involved in the planning and monitoring arrangements for food services and beverage/drinks provision.
- The care provider has a policy for food service and nutritional care, which is centred on the needs of users, and is performance managed in line with home country governance and/or a regulatory framework.
- Source: Nutrition Action Plan Delivery Board (2010)
Undernutrition is a longstanding problem and our ability to deliver an effective solution has proved elusive. The Nutrition Action Plan Delivery Board’s (2010) progress report and the government’s response (DH, 2010) provide the best guide to the way forward we have had for some time.
Healthcare professionals at the frontline of care now have an opportunity to make lasting and sustainable improvements to nutritional care in all settings. The support from the top is there and we must harness the enthusiasm and conviction of the frontline to bring about real improvements for generations to come. Undernutrition must become a thing of the past in modern health and social care.
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