According to the World Health Organization (WHO), malnutrition is estimated to contribute to more than a third of all child deaths around the world. Researchers at Southampton are influencing public policy to change healthcare practices and public attitudes to nutrition.
Nyovani Madise, Professor of Demography and Social Statistics at the University, explains that the lack of access to highly nutritious foods and problems such as inappropriate patterns of breastfeeding, contribute to malnutrition in developing countries. “Introduction of supplementary food can occur as early as the first month. Infection caused by contaminated water used in baby foods can lead to persistent diarrhoea, which also undermines a child’s nutritional status,” she says.
Malnutrition is not just an issue in developing countries; it is also a clinical and public problem in the UK, explains Marinos Elia, Professor of Clinical Nutrition and Metabolism at the National Institute for Health Research (NIHR) Southampton Biomedical Research Centre (BRC) in nutrition. Malnutrition affects more than three million people in Britain, costs an estimated £13bn a year or more and continues to go under-detected. When people are malnourished, their basic health and social care outcomes are significantly affected, making malnutrition an important patient safety issue.
“Our latest National surveys suggest that in England, at least 29 per cent of adults admitted to hospital, 18 per cent in mental health units, 12 per cent in sheltered housing and 35 per cent in care homes are malnourished, or at risk of malnutrition,” he says. “In the whole country this equates to five per cent of the population being malnourished or at risk of malnutrition and expenditure on malnutrition is the same, if not greater than expenditure on obesity in the UK,” he adds.
In order to prevent malnutrition, a joined up approach is needed, both at home and abroad. Nyovani explains that good quality research into the reasons behind malnutrition is vital to understand the problem. “We also know that poor infant feeding patterns are closely linked with poverty, so we need to address the causes of poverty, tackle disease and collaborate with local and national governments to educate the public and change people’s attitudes towards nutrition.”
Changing attitudes
Researchers at the Medical Research Council (MRC) Lifecourse Epidemiology Unit (LEU) at the University are indeed changing attitudes towards nutrition in the UK. In the landmark Southampton Women’s Survey (SWS), a study of 12,500 women aged between 20 and 34 recruited before they became pregnant, the team, led by Professor Cyrus Cooper, Director of the MRC LEU, found that lifestyle considerations such as diet, employment, social factors and levels of fitness and exercise have an influence on foetal and infant development.
The SWS also indicated that women withlower educational attainment may suffer from health problems such as obesityand often do not prepare for pregnancy by changing their diet and lifestyle. As aresult, their children are less likely to have a diet that conforms to the government’s guidelines for nutrition and are at higher risk of having problems in later life. “This large collaborative study demonstrates the impact of population science on health policy for future generations. The survey continues to yield invaluable insights into maternal health,” says Cyrus.
In developing countries, Nyovani has also found that more educated women are more likely to have healthy children. “If they are more educated, they are more likely to have a good job, be knowledgeable about the right foods for infants and children,
and negotiate the right medical care for them when they are sick,” she says. Nyovani and her team work with policy makers to educate women on the appropriate foods for them during pregnancy and for their babies as they grow. Her research on the socio-economic situation and characteristics of undernourished children in six African countries, found that there was a correlation between poor feeding practices, disease and child mortality.
“Feeding practices of infants in developing countries usually include starting babies as young as one or two months old on a cereal-based porridge as a supplement to breastfeeding. The porridge is made using contaminated water which causes infection and disease,” says Nyovani. “Our research on child health has contributed to changes in policies in Malawi, Kenya and the WHO.”
In the slums of Nairobi, Nyovani and her collaborators have set up a counselling support scheme that teaches pregnant women about what they should be eating during pregnancy to give their babies the best start. “We also educate the women on the importance of breastfeeding for building up the immune systems and cognitive development of infants, and we encourage them not to introduce supplementary feeding too early because we know that this can cause serious illness from contaminated water,” she says. So far the team has recruited 800 women on to the scheme and counsellors follow the progress of their baup until they are one year old in order to advise them on the early development of their children.
Simple solutions
In the UK, Marinos and his team at the BRC in association with BAPEN, a charitable association that raises awareness of malnutrition, have developed a bedside tool that assesses whether a patient is malnourished or not. “The Malnutrition Universal Screening Tool (MUST) is based on three criteria: whether the patient has experienced weight loss, what the patient’s weight is now and whether the patient is likely to lose more weight in the near future,” says Marinos.
MUST measures a person’s body mass index (BMI) and is a tool is based on a simple scoring system between zero and two. If the patient has a very low BMI, they score a two. Similarly, if the patient has lost a lot of weight they get another high score, and if they are acutely ill or unlikely to receive nutritional intake over the next five days, then again they score two. “The three scores can then be added up and if the score is two or higher they are at a high risk of being malnourished,” he says.
Based on the score from MUST, using a simple chart system, healthcare professionals can then decide the best course of treatment for the patient. Over the last few years, MUST has been incorporated into the majority of hospitals and care homes in the UK. “Supported by the Department of Health, the Royal College of Nursing, the Royal College of Physicians, the Registered Care Home Association and the National Institute for Health and Care Excellence (NICE), MUST is now in use by over 80 per cent of healthcare institutions in the UK,” Marinos explains. “The advantage of using MUST is that it can be used in different care settings, and we have created electronic versions and apps to simplify the technique to reduce the workload and move towards an automated system that patients can use themselves,” he adds.
Influencing policy
Nyovani explains that educating the public is the key to tackling malnutrition. “In Africa, interventions on their own can only go so far, and that is why we collaborate with local governments on every project we do. This is vital as local government help is what is needed to improve social services, educate women on nutrition and to improve water quality.”
In the UK, policy development and quality standards around malnutrition can only be built on a sound platform of solid and consistent evidence. In Southampton at the BRC, the work that Marinos and his colleagues have carried out has greatly influenced the National Institute of Health and Care Excellence (NICE) quality standards for nutrition support in adults. Marinos chaired the Quality Standards Committee providing the essential research knowledge, experience and leadership to develop the new standards that will transform the delivery of care.
The BRC, which illustrates the importance of collaboration between the NHS, the MRC and the University, has also played a key role in developing the International Malnutrition Taskforce (IMTF), a major influencer and developer of global malnutrition policy and practice. Using research from the BRC, the IMTF has identified two key research priorities that focus on the needs and care of children with severe acute malnutrition and moderate malnutrition across the world. The research priorities are: the need to be able to accurately determine the pattern of growth in children recovering from malnutrition, and the need to better understand the nutritional requirements of children recovering from malnutrition.
Going forward researchers in Southampton will continue to work with healthcare providers to identify the research priorities of importance to clinicians and patients so that better studies can be designed and delivered that more effectively address malnutrition issues, and work with industry to develop therapeutic pathways to maximise the quality and effectiveness of nutritional care.
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- Department for Health
- National Institute for Health Research
- Biomedical Research Ctr
- Southampton Women’s Study
- BAPEN
- NICE
- Royal College of Nursing
- MUST
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