- Email: [email protected]
Putting medical nutrition onto the international agenda: Actions by the European Nutrition for Health Alliance
ARTICLE IN PRESS Clinical Nutrition Supplements (2007) 2, 39–43
Available at www.sciencedirect.com
http://intl.elsevierhealth.com/journals/clnu
REVIEW
Putting medical nutrition onto the international agenda: Actions by the European Nutrition for Health Alliance Pascal Garel HOPE, European Hospital and Healthcare Federation, Auguste Reyers 207-209, BE-1030 Brussels, Belgium
KEYWORDS Malnutrition; Ageing; Public health; Stakeholders; Alliance; Partnerships
Summary Most attention from the public, policy makers and health promotion campaigns in relation to nutrition is aimed at obesity. Until recently, this has overshadowed another facet of poor nutrition, whereby inadequate nutritional intake—often associated with disease—leads to weight loss, impaired body function and poor clinical outcome. Malnutrition is highly prevalent but is frequently unrecognised and untreated. It not only compromises health outcomes by impairing response to medical treatment, delaying recovery and increasing mortality, but also severely impacts on the economic and social burden to carers and healthcare systems. Malnutrition is a public health and societal issue of at least equal importance to obesity and must be considered to be a disease in its own right. There is an urgent need to bridge across professional and sectoral divides to find sustainable solutions. To tackle malnutrition requires a coherent and comprehensive strategy, both at the European and national levels. A group of stakeholders from across the European health arena recently formed the European Nutrition for Health Alliance (ENHA) in a united effort to raise awareness of the importance and the urgency of the issue of malnutrition and to build an agenda for action, both at European level and in individual countries. Its overall objective is to raise awareness of the pressing need to prevent malnutrition and ensure that effective nutritional support is available to all those affected in the community and across all clinical settings. The ENHA consists of representatives of several key European stakeholders in the fields of nutrition, health and social care and policy. These partnerships create the basis and serve as an implementation network to reach target groups at EU and national levels. An action plan has been developed and a number of steps have already been taken towards implementation. & 2007 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Tel.: +32 2 742 13 20; fax: +32 2 742 13 25.
E-mail address: [email protected]. URL: http://www.hope.be (P. Garel). 1744-1161/$ - see front matter & 2007 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved. doi:10.1016/j.clnu.2007.04.005
ARTICLE IN PRESS 40
P. Garel
Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 How big is the malnutrition problem? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Addressing the problem: effectiveness of interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Multi-stakeholder approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 The formation of the European Nutrition for Health Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 The ENHA vision and goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 The ENHA achievements and activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Introduction There is growing political understanding of the role that nutrition plays in the onset and progression of many diseases. In parallel, media attention is often intense. All European governments have ‘‘Health promotion campaigns’’ aimed primarily at addressing obesity and its associated diseases, especially diabetes and cardiovascular disease. The health promotion efforts generally aim to reduce the significant impact these conditions have on the individual, society and healthcare resources. Attention to nutrition and in particular healthy eating is a core principle. These conditions are recognised as major public health issues and, particularly in the case of obesity, are clearly visible to society. At the other end of the spectrum of poor nutritional status are the individuals suffering from malnutrition. Most malnourished people are either in their own homes, in some form of residential care home or in hospital. Malnutrition is thus much less visible to society than obesity, and does not attract the same level of political or media attention. Even attention from clinicians managing the care of malnourished individuals is often deficient.1 Many patients will not have their nutritional status assessed at any time during their care. Despite the availability of simple screening tools for nutritional status that have been validated across healthcare settings (e.g., the ‘MUST’ tool2), a recent survey of general practitioners in the UK found that 88% were not aware of any screening tools and 40% did not give any dietary advice to patients at risk of malnutrition.3 Only 13% of family doctors surveyed always referred a patient with or at risk of malnutrition to a dietitian.
How big is the malnutrition problem? Malnutrition has a high prevalence across all ages as well as clinical and social settings.1 It is the older person, among the most vulnerable in society, who is most at risk of malnutrition and its consequences.4 As many as 50% of all patients admitted to hospital either have or are at risk of malnutrition 5–7 and depending on the survey and the care setting this figure could be as high as 85% or more.1 The number of people suffering from malnutrition rises from around 50% in persons over 60 years to 77% in persons over 80.7 The common risk factors for malnutrition in the elderly are summarised in Table 1.8
The economic and personal costs associated with untreated malnutrition are substantial. A recent study by BAPEN in the UK9,10 showed that the overall cost of managing patients with medium and high risk of diseaserelated malnutrition is £7.3 billion. The annual additional healthcare costs of managing these patients compared with an equivalent number of patients at low risk of malnutrition was estimated to be over £5.3 billion. Most of this incremental cost was due to more frequent and more expensive hospital inpatient spells, and greater need for long-term care. The figure of £7.3 billion represents nearly 10% of the UK total expenditure on health. A reduction of just 1% in the number of patients suffering from malnutrition could save the NHS in the UK up to £70 million. The costs of managing patients with malnutrition may be substantially more than that spent on managing obesity and its co-morbidities, which has been estimated by the House of Commons Health Committee to be £3.7 billion in the UK.11 Similar calculations have not yet been undertaken in other countries, and although costs are accounted for differently in different countries, the costs of treating Table 1
Risk factors for malnutrition in older people.
Risk factors
Examples
Clinical factors
Lifestyle and social factors
Lack of knowledge about food,
Poor appetite Poor dentition Loss of taste and smell Disability and limited mobility Drug interactions Other disease states (cancer, diabetes, stroke, etc.)
cooking and nutrition
Isolation and loneliness Poverty Inability to shop or prepare food Psychological factors
Confusion Depression Anxiety Bereavement Dementia
Adapted from Hickson (2006).8
ARTICLE IN PRESS Putting medical nutrition onto the international agenda patients with malnutrition are likely to be of the same order of magnitude irrespective of the healthcare system.
Addressing the problem: effectiveness of interventions The causes and consequences of malnutrition are multisectoral and thus interventions must be targeted at all care settings. There is a large body of evidence which demonstrates the clinical value of nutritional intervention in different healthcare settings.1 Pragmatic studies have shown that when appropriate treatment interventions are put in place the results can be dramatic. For example, the Belgian Geriatric study group12 demonstrated a significant reduction in length of hospital stay in geriatric patients. Similarly, in the community, Arnaud-Battandier showed that use of oral nutritional supplements in older people resulted in lower medical costs due to less hospital admissions, and less nursing and other medical time.13
Multi-stakeholder approach Over the years, there have been many publications on the problem of malnutrition but to date these have had limited impact in improving either the clinical practice of healthcare professionals, or changing health policy or society’s perceptions. A multi-stakeholder approach has a greater chance of success as each partner contributes a different perspective and this helps to highlight how the issue affects all sectors, not just the patient and the healthcare professional. Malnutrition is a societal issue, affecting many individuals in some way either directly, e.g., via a malnourished older family member, or indirectly, e.g., via consumption of healthcare resources in managing the complications caused by malnutrition which in turn may limit the resources available to adequately treat other conditions.
The formation of the European Nutrition for Health Alliance In response to the raising of the malnutrition issue at the Dutch EU presidency conference in The Hague in September 2004, a group of interested stakeholders from across the European healthcare arena recognised that all stakeholders must take ownership and action to address malnutrition across all care settings and sectoral divides. This led to the formation of the European Nutrition for Health Alliance (ENHA) which consists of representatives of several key European stakeholder bodies in the fields of nutrition, health and social care and policy (see Table 2), together with other stakeholders from the political arena.
The ENHA vision and goals For truly effective action to be taken on malnutrition, it has to be seen as a public health issue of equal magnitude and importance as obesity. With this in mind the first goal for the ENHA is to get malnutrition seen and treated as a disease in its own right. Recognising the problem is just the first step;
41
Table 2 Founding members of the European Nutrition for Health Alliance Committee. International Association of Gerontology/EUGMS European Society for Clinical Nutrition and Metabolism (ESPEN) HOPE (Standing Committee of the Hospitals of the European Union) Association Internationale de la Mutalite´ (AIM) De Friesland Health Insurance International Longevity Centre UK European Nurse Directors Association
implementing actions and nutritional care plans are essential if real improvements are to be made in patient care and clinical outcomes in this vulnerable group of people. The Alliance will seek to facilitate the sharing of best practices, the introduction of patient orientated nutrition care plans, lobbying for medical nutrition to be considered as part of future health policies and targets at EU and national level, and to improve nutritional education in all sectors of society. To achieve this the Alliance will attempt to
Raise awareness of the issue. Ensure that all stakeholders take responsibility and accountability for the issue.
Seek new and innovative finance and delivery models to address the problem.
Build a public media campaign on malnutrition. The key objectives of the ENHA are shown in Table 3.
The ENHA achievements and activities The ENHA has formed partnerships and works alongside many key non-governmental organisation (NGO) groups and patient organisations as well as representatives from the political arena at both EU and national level. On 14th September 2005, stakeholders from across Europe gathered in London for the inaugural conference of the ENHA. Delegates were invited from across a broad spectrum of health, residential and community care. The result of this conference was a call for action14 which included three key elements to advance progress against malnutrition in older people (Table 4). Through this multi-stakeholder approach, together with the British Association of Parenteral and Enteral Nutrition (BAPEN), the International Longevity Centre UK and the Parliamentary Food and Health Forum in the UK, the ENHA held a workshop at the House of Lords in London on 21st March 2006. This discussion and follow-up consultation led to the production of a policy brief15 published on 17th May 2006 that has been forwarded to the UK Department of Health. This document included seven key recommendations for policy makers (see Table 5). Further widening and strengthening of partnerships is expected to follow from the second EU Conference held in Brussels on 22nd November 2007 (see www.Europeannutrition.org).
ARTICLE IN PRESS 42
P. Garel
Table 3 Key objectives of the European Nutrition for Health Alliance.
Table 4 (continued ) Key messages
To raise awareness of the urgent need to prevent
good eating habits in their homes Malnutrition starts in the community; we need to develop communitylevel interventions and services to address the predisposing risk factors for malnutrition in communities Prevention of malnutrition must be a key public health goal; this requires adequate resourcing and sustainability Malnutrition cannot be dismissed as an inevitable consequence of old age; neglecting to address it is blatant age discrimination
malnutrition in the European Union and ensure that effective nutritional support is available to all those affected in the community and across all clinical settings Obtain recognition of malnutrition as a huge societal issue with significant economic consequences Obtain recognition that malnutrition is preventable, treatable and curable Convince policymakers and stakeholders that solutions are available, successful and affordable and that they must implement them All patients who need medical nutrition receive it and it is reimbursed Involve patients and consumers to raise awareness and political relevance Urge stakeholders to accept responsibility and take action
Table 4 Calls to action resulting from the inaugural conference of the ENHA held in London on 14th September 2005.14 Key messages
Implications
1. Malnutrition is ‘alive and Malnutrition is a serious killing’. It must be and preventable public recognized as a serious health problem; disease in its own right dedicated health promotion efforts are needed Screening tools exist; proactive detection and targeted screening programmes are needed Comprehensive treatment guidelines exist; they must be implemented Preventing and treating malnutrition should be made part of the standard medical curriculum 2. We can no longer afford to neglect the issue of malnutrition. It must be recognized as a serious social and economic issue. Its high prevalence should not be tolerated
Raised awareness and training of all health and social care professionals is vital; this applies to clinical and community settings. Raised awareness amongst older people themselves is essential; older people should be empowered to foster
Implications
3. All stakeholders need to take ownership and action to address malnutrition. Malnutrition occurs across all settings. Solutions require public–private partnerships that span across health and social care
Management of malnutrition must be person-centred; coordination across all professionals and care settings is needed for comprehensive and lasting solutions to be implemented There must be a coherent reimbursement policy for nutritional support across health and social care systems Insurance companies and third-party payers must allow for comprehensive coverage of nutritional support
Conclusions Malnutrition, like obesity, is a major public health issue, which has a high personal, economic and social cost. The costs of malnutrition have repercussions for all care settings including social services. Funding of appropriate interventions from better nutrition in the home to clinical nutrition in both the community and the hospital is inconsistent. If we are to prevent both the effects of malnutrition and the burden of payment falling indiscriminately on the most vulnerable in society, policy makers and payers must fund solutions, from their health and social budgets, to defeat malnutrition.
ARTICLE IN PRESS Putting medical nutrition onto the international agenda
Table 5 Key recommendations for policy makers in the UK, presented in the ‘‘Malnutrition among Older People in the Community. Policy Recommendations for Change’’ UK policy report, 17th May 2006.15
Malnutrition must be incorporated into the public health agenda
Addressing malnutrition in older people in the community requires an inter-sectoral approach
Raise awareness of malnutrition amongst older people, their families and the public at large
Ensure that access to good nutrition is incorporated into local and community planning
Develop adapted and accredited training in nutrition for all health, social care professionals and associated personnel Embed the practice of screening for malnutrition in the community by health, social care and community service providers and professionals Define standards and pathways of care for preventing and treating malnutrition in the community
The causes of malnutrition are multi-faceted and whilst implementing effective solutions may be complex, they will be successfully accomplished through political engagement at a European, national and community level and through raising public awareness about the risks of malnutrition. Governments would be seen as negligent if they did not attempt to tackle the growing threat of obesity in our society. Why does malnutrition, which disproportionately affects the older person, not receive the same attention? Across Europe, society is ageing so the numbers at risk of malnutrition will continue to rise, placing an ever-increasing strain on scarce healthcare resources if actions are not taken now. By acting together to raise awareness, to assist in the implementation of screening tools and ensuring that those patients who require it can receive appropriate and fully reimbursed nutritional support, this issue can be resolved. The solutions are available and achievable and a multidisciplinary approach, with dietitians at the core, is needed if malnutrition is to be eliminated from within our communities. ‘‘How will history judge the early 21st century? If things go on as they are, the verdict will be dismay and condemnation, that wealthy societies and established social protection systems could allow the tragedy of malnutrition to occur in such a large segment of the population. This just not tolerable, and the ENHA, with growing support, is determined to tackle this issue’’ (Mel Read, former MEP)16
43
References 1. Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence based approach to treatment. Wallingford: CABI Publishing; 2003. 2. Elia M, editor. The MUST Report. A Report by the Malnutrition Advisory Group of the British Association of Parenteral and Enteral Nutrition (BAPEN). Redditch: BAPEN; 2003. 3. Bacon N. Malnutrition in an ageing society. Presentation to the European Nutrition for Health Alliance Conference, 2005. /www.european-nutrition.orgS. 4. Furman EF. Undernutrition in older adults across the continuum of care. J Gerontol Nurs 2006;32:22–7. 5. Edington J, Boorman J, Durrant ER, et al. Prevalence of malnutrition on admission to four hospitals in England. The malnutrition prevalence group. Clin Nutr 2000;19:191–5. 6. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. Br Med J 1994;308:945–8. 7. Kyle U, Unger P, Mensi N, Genton L, Pichard C. Nutrition status in patients younger and older than 60y at hospital admission: a controlled population study in 995 subjects. Nutrition 2002; 18:463–9. 8. Hickson M. Malnutrition and ageing. Post Grad Med J 2006;82: 2–8. 9. Elia M, Stratton R, Russell C, Green C, Pang, F. The cost of disease-related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. Report by the Health Economic Group of the British Association of Parenteral and Enteral Nutrition (BAPEN). Redditch: BAPEN; 2005. 10. Russell CA. Impact of malnutrition on healthcare costs and economic considerations for the use of oral nutritional supplements. Clin Nutr Supp 2007;2:25–32 (this issue). 11. House of Commons Health Committee. Obesity (volume 1). In: Third report of session 2003–2004, editor. London: The Stationery Office Limited; 2004. 12. Pepersack T. Geriatrics peer review: outcome of continuous process improvement of nutritional care programme among geriatric units in Belgium. Presentation to the European Nutrition for Health Alliance Conference, 2005. /www.europeannutrition.orgS. 13. Arnaud-Battandier F, Malvy D, Jeandel D, et al. Use of oral supplements in malnourished elderly patients living in the community: a pharmaco-economic study. Clin Nutr 2004;23: 1096–103. 14. European Nutrition for Health Alliance. Malnutrition within an ageing population: a call for action. Report on the inaugural conference of the European Nutrition for Health Alliance, London, 14th September 2005. /www.europeannutrition.orgS. 15. Baeyens JP, Elia M, Greengross S, Rea N. Malnutrition among older people in the community. Policy recommendations for change. A UK policy report by European Nutrition for Health Alliance, British Association for Parenteral and Enteral Nutrition, International Longevity Centre — UK in collaboration with the Associate Parliamentary Food and health Forum, 2006 /www.european-nutrition.orgS. 16. Read M. Opening address at the inaugural conference of the European Nutrition for Health Alliance. London 14th September 2005. /www.european-nutrition.orgS.
Available at www.sciencedirect.com
http://intl.elsevierhealth.com/journals/clnu
REVIEW
Putting medical nutrition onto the international agenda: Actions by the European Nutrition for Health Alliance Pascal Garel HOPE, European Hospital and Healthcare Federation, Auguste Reyers 207-209, BE-1030 Brussels, Belgium
KEYWORDS Malnutrition; Ageing; Public health; Stakeholders; Alliance; Partnerships
Summary Most attention from the public, policy makers and health promotion campaigns in relation to nutrition is aimed at obesity. Until recently, this has overshadowed another facet of poor nutrition, whereby inadequate nutritional intake—often associated with disease—leads to weight loss, impaired body function and poor clinical outcome. Malnutrition is highly prevalent but is frequently unrecognised and untreated. It not only compromises health outcomes by impairing response to medical treatment, delaying recovery and increasing mortality, but also severely impacts on the economic and social burden to carers and healthcare systems. Malnutrition is a public health and societal issue of at least equal importance to obesity and must be considered to be a disease in its own right. There is an urgent need to bridge across professional and sectoral divides to find sustainable solutions. To tackle malnutrition requires a coherent and comprehensive strategy, both at the European and national levels. A group of stakeholders from across the European health arena recently formed the European Nutrition for Health Alliance (ENHA) in a united effort to raise awareness of the importance and the urgency of the issue of malnutrition and to build an agenda for action, both at European level and in individual countries. Its overall objective is to raise awareness of the pressing need to prevent malnutrition and ensure that effective nutritional support is available to all those affected in the community and across all clinical settings. The ENHA consists of representatives of several key European stakeholders in the fields of nutrition, health and social care and policy. These partnerships create the basis and serve as an implementation network to reach target groups at EU and national levels. An action plan has been developed and a number of steps have already been taken towards implementation. & 2007 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Tel.: +32 2 742 13 20; fax: +32 2 742 13 25.
E-mail address: [email protected]. URL: http://www.hope.be (P. Garel). 1744-1161/$ - see front matter & 2007 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved. doi:10.1016/j.clnu.2007.04.005
ARTICLE IN PRESS 40
P. Garel
Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 How big is the malnutrition problem? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Addressing the problem: effectiveness of interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Multi-stakeholder approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 The formation of the European Nutrition for Health Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 The ENHA vision and goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 The ENHA achievements and activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Introduction There is growing political understanding of the role that nutrition plays in the onset and progression of many diseases. In parallel, media attention is often intense. All European governments have ‘‘Health promotion campaigns’’ aimed primarily at addressing obesity and its associated diseases, especially diabetes and cardiovascular disease. The health promotion efforts generally aim to reduce the significant impact these conditions have on the individual, society and healthcare resources. Attention to nutrition and in particular healthy eating is a core principle. These conditions are recognised as major public health issues and, particularly in the case of obesity, are clearly visible to society. At the other end of the spectrum of poor nutritional status are the individuals suffering from malnutrition. Most malnourished people are either in their own homes, in some form of residential care home or in hospital. Malnutrition is thus much less visible to society than obesity, and does not attract the same level of political or media attention. Even attention from clinicians managing the care of malnourished individuals is often deficient.1 Many patients will not have their nutritional status assessed at any time during their care. Despite the availability of simple screening tools for nutritional status that have been validated across healthcare settings (e.g., the ‘MUST’ tool2), a recent survey of general practitioners in the UK found that 88% were not aware of any screening tools and 40% did not give any dietary advice to patients at risk of malnutrition.3 Only 13% of family doctors surveyed always referred a patient with or at risk of malnutrition to a dietitian.
How big is the malnutrition problem? Malnutrition has a high prevalence across all ages as well as clinical and social settings.1 It is the older person, among the most vulnerable in society, who is most at risk of malnutrition and its consequences.4 As many as 50% of all patients admitted to hospital either have or are at risk of malnutrition 5–7 and depending on the survey and the care setting this figure could be as high as 85% or more.1 The number of people suffering from malnutrition rises from around 50% in persons over 60 years to 77% in persons over 80.7 The common risk factors for malnutrition in the elderly are summarised in Table 1.8
The economic and personal costs associated with untreated malnutrition are substantial. A recent study by BAPEN in the UK9,10 showed that the overall cost of managing patients with medium and high risk of diseaserelated malnutrition is £7.3 billion. The annual additional healthcare costs of managing these patients compared with an equivalent number of patients at low risk of malnutrition was estimated to be over £5.3 billion. Most of this incremental cost was due to more frequent and more expensive hospital inpatient spells, and greater need for long-term care. The figure of £7.3 billion represents nearly 10% of the UK total expenditure on health. A reduction of just 1% in the number of patients suffering from malnutrition could save the NHS in the UK up to £70 million. The costs of managing patients with malnutrition may be substantially more than that spent on managing obesity and its co-morbidities, which has been estimated by the House of Commons Health Committee to be £3.7 billion in the UK.11 Similar calculations have not yet been undertaken in other countries, and although costs are accounted for differently in different countries, the costs of treating Table 1
Risk factors for malnutrition in older people.
Risk factors
Examples
Clinical factors
Lifestyle and social factors
Lack of knowledge about food,
Poor appetite Poor dentition Loss of taste and smell Disability and limited mobility Drug interactions Other disease states (cancer, diabetes, stroke, etc.)
cooking and nutrition
Isolation and loneliness Poverty Inability to shop or prepare food Psychological factors
Confusion Depression Anxiety Bereavement Dementia
Adapted from Hickson (2006).8
ARTICLE IN PRESS Putting medical nutrition onto the international agenda patients with malnutrition are likely to be of the same order of magnitude irrespective of the healthcare system.
Addressing the problem: effectiveness of interventions The causes and consequences of malnutrition are multisectoral and thus interventions must be targeted at all care settings. There is a large body of evidence which demonstrates the clinical value of nutritional intervention in different healthcare settings.1 Pragmatic studies have shown that when appropriate treatment interventions are put in place the results can be dramatic. For example, the Belgian Geriatric study group12 demonstrated a significant reduction in length of hospital stay in geriatric patients. Similarly, in the community, Arnaud-Battandier showed that use of oral nutritional supplements in older people resulted in lower medical costs due to less hospital admissions, and less nursing and other medical time.13
Multi-stakeholder approach Over the years, there have been many publications on the problem of malnutrition but to date these have had limited impact in improving either the clinical practice of healthcare professionals, or changing health policy or society’s perceptions. A multi-stakeholder approach has a greater chance of success as each partner contributes a different perspective and this helps to highlight how the issue affects all sectors, not just the patient and the healthcare professional. Malnutrition is a societal issue, affecting many individuals in some way either directly, e.g., via a malnourished older family member, or indirectly, e.g., via consumption of healthcare resources in managing the complications caused by malnutrition which in turn may limit the resources available to adequately treat other conditions.
The formation of the European Nutrition for Health Alliance In response to the raising of the malnutrition issue at the Dutch EU presidency conference in The Hague in September 2004, a group of interested stakeholders from across the European healthcare arena recognised that all stakeholders must take ownership and action to address malnutrition across all care settings and sectoral divides. This led to the formation of the European Nutrition for Health Alliance (ENHA) which consists of representatives of several key European stakeholder bodies in the fields of nutrition, health and social care and policy (see Table 2), together with other stakeholders from the political arena.
The ENHA vision and goals For truly effective action to be taken on malnutrition, it has to be seen as a public health issue of equal magnitude and importance as obesity. With this in mind the first goal for the ENHA is to get malnutrition seen and treated as a disease in its own right. Recognising the problem is just the first step;
41
Table 2 Founding members of the European Nutrition for Health Alliance Committee. International Association of Gerontology/EUGMS European Society for Clinical Nutrition and Metabolism (ESPEN) HOPE (Standing Committee of the Hospitals of the European Union) Association Internationale de la Mutalite´ (AIM) De Friesland Health Insurance International Longevity Centre UK European Nurse Directors Association
implementing actions and nutritional care plans are essential if real improvements are to be made in patient care and clinical outcomes in this vulnerable group of people. The Alliance will seek to facilitate the sharing of best practices, the introduction of patient orientated nutrition care plans, lobbying for medical nutrition to be considered as part of future health policies and targets at EU and national level, and to improve nutritional education in all sectors of society. To achieve this the Alliance will attempt to
Raise awareness of the issue. Ensure that all stakeholders take responsibility and accountability for the issue.
Seek new and innovative finance and delivery models to address the problem.
Build a public media campaign on malnutrition. The key objectives of the ENHA are shown in Table 3.
The ENHA achievements and activities The ENHA has formed partnerships and works alongside many key non-governmental organisation (NGO) groups and patient organisations as well as representatives from the political arena at both EU and national level. On 14th September 2005, stakeholders from across Europe gathered in London for the inaugural conference of the ENHA. Delegates were invited from across a broad spectrum of health, residential and community care. The result of this conference was a call for action14 which included three key elements to advance progress against malnutrition in older people (Table 4). Through this multi-stakeholder approach, together with the British Association of Parenteral and Enteral Nutrition (BAPEN), the International Longevity Centre UK and the Parliamentary Food and Health Forum in the UK, the ENHA held a workshop at the House of Lords in London on 21st March 2006. This discussion and follow-up consultation led to the production of a policy brief15 published on 17th May 2006 that has been forwarded to the UK Department of Health. This document included seven key recommendations for policy makers (see Table 5). Further widening and strengthening of partnerships is expected to follow from the second EU Conference held in Brussels on 22nd November 2007 (see www.Europeannutrition.org).
ARTICLE IN PRESS 42
P. Garel
Table 3 Key objectives of the European Nutrition for Health Alliance.
Table 4 (continued ) Key messages
To raise awareness of the urgent need to prevent
good eating habits in their homes Malnutrition starts in the community; we need to develop communitylevel interventions and services to address the predisposing risk factors for malnutrition in communities Prevention of malnutrition must be a key public health goal; this requires adequate resourcing and sustainability Malnutrition cannot be dismissed as an inevitable consequence of old age; neglecting to address it is blatant age discrimination
malnutrition in the European Union and ensure that effective nutritional support is available to all those affected in the community and across all clinical settings Obtain recognition of malnutrition as a huge societal issue with significant economic consequences Obtain recognition that malnutrition is preventable, treatable and curable Convince policymakers and stakeholders that solutions are available, successful and affordable and that they must implement them All patients who need medical nutrition receive it and it is reimbursed Involve patients and consumers to raise awareness and political relevance Urge stakeholders to accept responsibility and take action
Table 4 Calls to action resulting from the inaugural conference of the ENHA held in London on 14th September 2005.14 Key messages
Implications
1. Malnutrition is ‘alive and Malnutrition is a serious killing’. It must be and preventable public recognized as a serious health problem; disease in its own right dedicated health promotion efforts are needed Screening tools exist; proactive detection and targeted screening programmes are needed Comprehensive treatment guidelines exist; they must be implemented Preventing and treating malnutrition should be made part of the standard medical curriculum 2. We can no longer afford to neglect the issue of malnutrition. It must be recognized as a serious social and economic issue. Its high prevalence should not be tolerated
Raised awareness and training of all health and social care professionals is vital; this applies to clinical and community settings. Raised awareness amongst older people themselves is essential; older people should be empowered to foster
Implications
3. All stakeholders need to take ownership and action to address malnutrition. Malnutrition occurs across all settings. Solutions require public–private partnerships that span across health and social care
Management of malnutrition must be person-centred; coordination across all professionals and care settings is needed for comprehensive and lasting solutions to be implemented There must be a coherent reimbursement policy for nutritional support across health and social care systems Insurance companies and third-party payers must allow for comprehensive coverage of nutritional support
Conclusions Malnutrition, like obesity, is a major public health issue, which has a high personal, economic and social cost. The costs of malnutrition have repercussions for all care settings including social services. Funding of appropriate interventions from better nutrition in the home to clinical nutrition in both the community and the hospital is inconsistent. If we are to prevent both the effects of malnutrition and the burden of payment falling indiscriminately on the most vulnerable in society, policy makers and payers must fund solutions, from their health and social budgets, to defeat malnutrition.
ARTICLE IN PRESS Putting medical nutrition onto the international agenda
Table 5 Key recommendations for policy makers in the UK, presented in the ‘‘Malnutrition among Older People in the Community. Policy Recommendations for Change’’ UK policy report, 17th May 2006.15
Malnutrition must be incorporated into the public health agenda
Addressing malnutrition in older people in the community requires an inter-sectoral approach
Raise awareness of malnutrition amongst older people, their families and the public at large
Ensure that access to good nutrition is incorporated into local and community planning
Develop adapted and accredited training in nutrition for all health, social care professionals and associated personnel Embed the practice of screening for malnutrition in the community by health, social care and community service providers and professionals Define standards and pathways of care for preventing and treating malnutrition in the community
The causes of malnutrition are multi-faceted and whilst implementing effective solutions may be complex, they will be successfully accomplished through political engagement at a European, national and community level and through raising public awareness about the risks of malnutrition. Governments would be seen as negligent if they did not attempt to tackle the growing threat of obesity in our society. Why does malnutrition, which disproportionately affects the older person, not receive the same attention? Across Europe, society is ageing so the numbers at risk of malnutrition will continue to rise, placing an ever-increasing strain on scarce healthcare resources if actions are not taken now. By acting together to raise awareness, to assist in the implementation of screening tools and ensuring that those patients who require it can receive appropriate and fully reimbursed nutritional support, this issue can be resolved. The solutions are available and achievable and a multidisciplinary approach, with dietitians at the core, is needed if malnutrition is to be eliminated from within our communities. ‘‘How will history judge the early 21st century? If things go on as they are, the verdict will be dismay and condemnation, that wealthy societies and established social protection systems could allow the tragedy of malnutrition to occur in such a large segment of the population. This just not tolerable, and the ENHA, with growing support, is determined to tackle this issue’’ (Mel Read, former MEP)16
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