British Dietetic Association (BDA) – Written evidence (INQ0080)

About the BDA and Dietitians

• The British Dietetic Association (BDA), founded in 1936, is the professional association and trade union for dietitians in Great Britain and Northern Ireland. It is the nation’s largest organisation of food and nutrition professionals with over 9,500 members.

• Dietitians are highly qualified health professionals that assess, diagnose and treat diet and nutrition problems at an individual and wider public health level. They are statutorily regulated by the Health and Care Professions Council (HCPC), alongside other Allied Health Professions.

Good nutrition and hydration are vital for healthier ageing

• Good nutrition and hydration are fundamental to healthier ageing. An individual’s nutritional needs may change when they age. As people get older, energy needs may decrease due to reduced muscle bulk (lean body mass), increased fat stores and reduced physical activity. This can reduce basal metabolic rate, which can lower energy requirements. Many people say they don’t need to eat a lot, as they are less active. However, it’s likely the decrease in energy is only 100-400 calories per day and their requirements for other nutrients (including protein and vitamins and minerals) are unchanged or may be higher than for younger people. It is therefore important that people still eat regular nutritious meals.

• Good nutrition throughout life is essential to prevent problems arising in older age. Obesity, diabetes, osteoporosis, mental health and much more are all impacted directly by diet and nutrition throughout the life course, even if their impacts are not felt until later in life. Diet is now the biggest modifiable factor in determining health, more than even smoking. Estimates from as long ago as 2006-07 are that poor diet costs the NHS £5.8 billion annually, this figure will only have increased[1].

• Energy requirements can increase due to acute or chronic disease. For example, chronic obstructive pulmonary disease (COPD) can increase the effort required to breathe and cause inflammation, which can cause more energy to be used up. In Parkinson’s disease, people may experience involuntary movements, which can increase energy expenditure. The best way to find out if you are having too many or too few calories (energy) is to establish if your weight is stable or if you are losing or gaining weight.

Dehydration

• Older people can be vulnerable to dehydration due to physiological changes in the ageing process. This can be complicated by many disease states, as well as mental and physical frailty, which can

further increase risk of dehydration. Age-related changes include a reduced sensation of thirst, and this may be more pronounced in those with Alzheimer’s disease or in those who have had a stroke.

• Dehydration has a number of significant impacts on health for elderly people
• Increased risk of hospital stays and death.
• Even mild dehydration can negatively affect mental performance and can increase feelings of

tiredness. Mental functions affected include memory, attention, concentration and reaction time.

• Low blood pressure, weakness, dizziness and increased risk of falls.
• Increased risk of developing pressure ulcers and skin conditions.
• Increased risk of urinary tract infections. Inadequate hydration is one of the main causes of acute kidney injury.
• Inadequate fluid intake is also one of the most common causes of constipation.

More information on good nutrition in older people

• Guide to good nutrition and hydration in older age – BDA and FOTE[2]

Malnutrition

• It is still widely believed that malnutrition (or more properly undernutrition) is a problem restricted to the developing world but this is sadly untrue. Older people aged over 65 are more likely than any other age group to suffer malnutrition in the UK, with an estimated 1.3 million older people undernourished[3]. Sadly, reduced appetite and weight loss have become regarded by some as a normal sign of getting older - but this isn't true.

• Malnutrition is defined by NICE as either, a BMI of less than 18.5 kg/m2, unintentional weight loss greater than 10% within the last 3–6 months or a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months[4].

• Malnutrition and mortality are usually closely linked. Malnutrition lengthens and increases the frequency of hospital stays[5], reduces quality of life and increases the risk of developing other diseases. The cost of malnutrition in England alone was estimated to be £19.6 billion per year in 2011/12, or more than 15% of the total public expenditure on health and social care[6].

• Malnutrition is also closely associated with frailty, which is a huge issue in primary care (OPSG guidance on frailty)

Causes of Malnutrition

• The reasons why people become malnourished are varied - it may be because they cannot afford food, can't properly prepare it due to physical disabilities, have lost their appetite or have another healthcare condition that makes eating and drinking more difficult.

• Poverty or concerns about affordability are also factors; a report by CEBR for Kellogg’s found that on average retired households spend the second highest proportion of gross income on food and drink; 11.2%. The average annual food bill for a retired household has increased by over 12% from 2012- 2017. Indeed, CEBR stated in 2013 that as many as 1.5million over-65s were in food poverty[7] – defined as spending more than 10% of household income on food.

• Access to food can also be problematic, even when affordability is not an issue. Age UK’s Food Shopping in Later Life report highlighted significant numbers of people over 65, and particularly over 80, who struggle to access shops, or have difficulty instore or with packaging[8].

• Difficulty eating or preparing food for whatever reason is another factor. This can include issues such as swallowing difficulties, mobility issues or problems with teeth or dentures. Even in healthcare settings, people can face problems with accessing food. The Adult Inpatient Survey in England (2016)[9] showed that 18% of patients reported not getting enough help from staff to eat their meals.

What action is needed?

• Malnutrition often goes unnoticed for too long, so much wider and more consistent screening in health, care and community settings is an important means of both helping us better understand the scale of the problem and target interventions to tackle it. Interventions such as BAPEN’s annual malnutrition screening week is one such effort that could be more widely supported to raise awareness amongst both professionals and the public.
   
• Because the causes of malnutrition are multifaceted, the solutions are similarly varied. Ensuring that patients have access to dietetic expertise be that in a hospital, care or community setting is important, as dietitians have been shown to be clinically and cost effective in the treatment of malnutrition[10].

• Supporting older people (be they in hospital or the community) to eat well could involve support to overcome physical or mental barriers, such as frailty, loneliness or mobility. We need to invest in services that help overcome these barriers, be that through care services or community services such as meals-on-wheels or lunch clubs.

What role could technology play?

• Giving older people access to advice and support digitally will be a key way of ensuring they can continue to live a healthy life in old age. It is unrealistic to expect all people to access dietetic and other support services directly, especially if people are more isolated geographically or physically restricted in some way. Telehealth, which is of increasing use in the NHS allows people to access expertise such as that of a dietitian from their home, and increased the number of people that dietitians can see in a typical clinic.

• Mobile tech and ‘wearables’ also offer better ways for health and care professionals to track and support patients and clients. Dietitians are already using apps to provide customised, “on the go” advice to clients to help them improve their diet, be that to lose weight or treat a healthcare condition. Although at the moment this is probably more popular amongst younger patients, increasing numbers of older people are likely to access these services to aid their health and wellbeing.

More information on malnutrition

• Hidden hunger and malnutrition in the elderly – APPG on Hunger[11]
• Managing malnutrition to improve lives and save money - BAPEN[12]

September 2019