The Patients Association Malnutrition Checklist helps patients and staff working in health and social care identify the potential risk of undernutrition in adults. Published in December 2018, the checklist aims to address the rising problems of undernutrition in older people, and could potentially improve the day-to-day lives and experiences of thousands of over-65s across the country.  

It is estimated that over 1.1 million people over 65 living in their own homes in the UK are currently undernourished, underweight or are not receiving appropriate nutrition to support and maintain their health and wellbeing. This poses a significant health risk for patients, with consequences from malnutrition including impaired recovery from illness and surgery, reduced muscle strength, more frequent falls and poorer clinical outcomes.

Developed by the Patients Association in collaboration with several health, social care and voluntary sector providers including Bournemouth University, the Malnutrition Pathway (Managing Adult Malnutrition in the Community), and Wessex Academic Health Science Network (Wessex AHSN), the checklist is a simple tool that helps healthcare staff and patients identify the potential risk of undernutrition, and offers signposting to information and sources of help to those likely to be at risk.  

It has been rigorously tested and refined over a period of two years, and has received positive feedback from patients and staff working in the health and social care sector.  Although it can be used by anyone, the new checklist is primarily intended for those aged over 65 and living in the community.

Rachel Power, Chief Executive of the Patients Association, said:

“The Patients Association Nutrition Checklist can play an important role in the drive to help identify undernutrition among older people and provide information and advice to improve weight gain. If malnutrition can be prevented or identified and treated at an early stage, it could reduce dependency on others and admissions to hospital and other care settings.

“The checklist is an effective tool that complements existing malnutrition screening resources. It has been praised by patients who find it easy to use and helpful, and by NHS staff for its practicality and simplicity. What we’d now like to see is the extensive take-up of this checklist in primary care and community settings to help address the problem of undernutrition, and to improve patients’ lives.”

Caroline Lecko, Clinical Improvement Manager (Nursing Directorate) at NHS Improvement, said: "The importance of the early identification of the risk of undernutrition cannot be underestimated. The Patients Association Nutrition Checklist is a valuable tool for patients, carers and healthcare professionals that will not only assist in supporting the early identification of risk but provide an opportunity for individuals to seek advice on maintaining a healthy weight and for healthcare professionals to provide person centred guidance to support the overall well-being of people across our healthcare systems."

Alison Smith, Lead Dietetic Prescribing Advisor at NHS Buckinghamshire CCG at the time of the pilot, and Chair of the British Dietetic Association Older People Specialist Group, said: “The nutrition checklist is a quick and simple tool that patients or staff can use to see if they need help with their eating. As well as identifying undernutrition, it also provides practical and straightforward advice for patients and carers, and helps health care professionals identify which patients require an in-depth discussion about their weight, eating and drinking.

“Poor nutrition has a significant impact on an individual’s health so identifying patients who need support in a timely manner is absolutely key – there is a real need for the nutrition checklist in the community.”

Lesley Carter, Malnutrition Task Force lead, said: "We all know that malnutrition can be the cause and consequences of ill health. Having access to the Patients Association Nutrition Checklist, a quick and simple tool which enables everyone to identify the risk of undernutrition, is key to raising awareness of poor nutrition in older people across communities and is a simple way to encourage the conversation.” 

The Patients Association has raised concerns about malnutrition in the UK for many years. In 2015, we published a paper which identified the need to raise awareness of malnutrition, both with professionals and with patients and relatives by using a nutrition checklist. In 2017 we published a report outlining the issue of undernutrition among children in Britain today.

How was the checklist developed?

The Patients Association Nutrition Checklist was developed and further refined following a successful pilot period. It was piloted in four different settings over three to six month periods, including in two GP practices, a domiciliary care provider and a fire and rescue service, as well as a local branch of Age UK. During the pilots, more than 400 people used the Patients Association Nutrition Checklist, with nearly 120 people identified as being at risk of undernutrition. These people received information and guidance that they would not have otherwise received.

As a result of these pilots, the content of the Patients Association Nutrition Checklist was refined and two versions developed, one for use by patients and their families, and the other for health, social care and volunteers supporting them. Individuals can use the checklist to identify their own risk of malnutrition, or the risk of malnutrition in someone they care for.

Concurrent validity of the Patients Association Nutrition Checklist against ‘MUST’

At the same time as the pilots of the Patients Association Nutrition Checklist in different settings were taking place, an independent research project was set up by Wessex AHSN and Bournemouth University. This was to assess the validity of the four questions in Section A of the Patients Association Nutrition Checklist as a measure of nutritional risk in comparison with the ‘Malnutrition Universal Screening Tool’ (‘MUST’).

A total of 312 older people (over 65 years) were recruited from lunch and activity clubs in Hampshire and Dorset. They were screened for nutritional risk, using both ‘MUST’ and Section A of the Patients Association Nutrition Checklist. It was important to understand how well the tool could be used, and offer the potential to be an early indicator of undernutrition. Data was collected by trained researchers, and subjected to statistical analysis. Anyone identified as being at risk of undernutrition was signposted to advice and guidance.

The research showed that Section A of the Patients Association Nutrition Checklist has acceptable sensitivity and specificity when compared with ‘MUST’. The checklist is not intended as a replacement for ‘MUST’ in clinical settings, but has potential to be used as a way to triage or identify those people who would benefit from further screening and advice. The study also showed that the Patients Association Nutrition Checklist has potential for early identification of undernutrition risk, as it identified people in the earlier stages of unintentional weight loss, and people whose appetite had been recently compromised.

The checklist therefore gives the opportunity for people identifying themselves as possibly at risk to self-screen and/or seek advice and for staff to follow up using NICE guidance (including potentially the use of ‘MUST’ by trained practitioners) and offer earlier signposting to dietary advice and appropriate health and social care support.

A positive impact on patient care

Patients have found the nutrition checklist extremely helpful, and it has improved their nutrition and quality of life. Below are profiles of a few patients who used the checklist during the pilot period – more examples can be found in the full report.

Older man receiving domiciliary care

“A domiciliary care locality manager used the Patients Association Nutrition Checklist with an elderly man after noticing that meals left in the microwave for him to warm up and eat were untouched. The Patients Association Nutrition Checklist helped develop a conversation with him, and led to him agreeing to have hot meals delivered instead.  Having a meal delivered hot makes it more likely that the client will eat. It also led to further conversations with his social worker to arrange for him to go to a day centre on additional days.”

Elderly housebound patient

“A housebound patient was referred for help with nutrition after a visit from the GP practice paramedic who went through the Patients Association Nutrition Checklist with her, revealing possible risk. She was frail and elderly and she had wounds. The trained member of staff explained about how to eat well when underweight.

The patient said she was using skimmed milk and was persuaded to switch to full-fat milk. She was given the leaflet ‘Food first – eating well for wound healing’. Her wounds have healed considerably and her weight has stabilised.”

How do health and care staff and volunteers feel about the new checklist?

When invited to give feedback and offer ideas for development, staff and volunteers across all the pilots were positive about the Patients Association Nutrition Checklist. The GP practices, domiciliary care organisation and voluntary sector provider which took part in the pilots all wish to carry on using it.

Staff involved in the pilots said it proved effective in providing initial indications of nutritional need (Section A) because:

 It is simple and easy for anyone to use (staff and patients)

  • It does not require measuring devices for weight and height
  • It does not require the ability to calculate percentages
  • It is low-key so it can be used to start an informal conversation with patients and indicate likely risk or offer reassurance.

Quotes from staff who used the checklist include:

  • “I feel I provided advice to two people not likely to be supported by anyone else, and that their diets would have worsened without the intervention” - Service Navigator and Assessment Officer, Age UK Southampton
  • “It has unlocked something – the moment we started talking about undernutrition and the Patients Association Nutrition Checklist, people’s attention shifted and they (staff) saw the relevance for a patient” - Public Health Nutritionist, linked to GP practice
  • “The Patients Association Nutrition Checklist has brought people in, everyone has got involved and it’s raised awareness massively across all staff members about nutrition. It’s been fantastic.” - GP practice staff member

Anne Holdoway, Consultant Dietitian and Chair of the Managing Adult Malnutrition in the Community, said: “Malnutrition has a major effect on a person’s quality of life making them weak, frail, more prone to illness and infections. The Patients Association Nutrition Checklist is a great tool for creating the conversation with patients and families about diet, unintentional weight loss and the anxiety that this can create and which can be easily overlooked. I anticipate that the checklist will be instrumental in guiding further actions to treat those at risk of malnutrition as soon as possible” 

Dr Anita Nathan, GP Member of the Managing Adult Malnutrition in the Community and member of the GPs Interested in Nutrition Group, said: “It is estimated that more than one in ten patients visiting GP surgeries are at risk of malnutrition and these patients have more GP contact than non-malnourished individuals. If we can start to identify more people who are at risk of malnutrition through the use of the Patients Association Nutrition Checklist, we can assist the management of patients earlier. By improving their nutritional status, patients are likely to reduce the time they are spending in hospital and improve their clinical outcomes.’’

Emily Holzhausen, Director of Policy and Public Affairs at Carers UK, said: “Carers UK’s research has shown that many people caring for relatives who are older, disabled or frail worry about whether the person they are caring for is getting the right nutrition. Having some fairly simple yet effective questions to start those conversations is particularly valuable for families as it can help them to turn their worry into practical action. Carers UK looks forward to the Patients Association Nutrition Checklist being rolled out widely, and seeing the difference that it makes to both the person needing care, as well as the carer." 

Watch a video about the new checklist

An animated video about the Patients Association Nutrition Checklist was developed for use in GP surgeries. The film was developed to explain the possibility of being undernourished or underweight, to introduce the Patients Association Nutrition Checklist and to give information about what actions to take.



DOWNLOAD

Full report: download our overview report on the nutrition checklist here.

Patient version: to complete the Patients Association Nutrition Checklist yourself, or for a family member or friend, click here.

Staff version: if you work in health or social care, please read our guide on using the checklist here. The checklist for staff is available in two versions: section A and section B:

You can also read our report following the GP pilots here.

Please note: We are keen to hear from patients and health care professionals who are using our checklist, and would like to hear your feedback about the impact it has had on your nutrition, or the patients you are caring for. Please keep us posted with feedback by emailing [email protected]