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Hertfordshire Nutrition and Wellbeing Service - identifying and addressing malnutrition in the community

Hertfordshire Independent Living Service is a charitable social enterprise supporting older people in Hertfordshire to live independently. It is the largest provider of meals on wheels in the country, providing hot nutritious food on behalf of Hertfordshire County Council, to thousands of older or vulnerable people.

More than just a meal
In 2015, the Nutrition and Wellbeing Service was launched, aiming to tackle malnutrition in the community. A small team of two dietitians and a registered nutritionist lead the service, offering a ‘Nutrition and Wellbeing check’ to all clients. The check consists of a visit from a member of the team, where nutritional status is assessed using the Malnutrition Universal Screening Tool (MUST) (See box 1). Questions around health and lifestyle are asked to ascertain the root cause of malnutrition, and whether the client can be supported in any other way (see box 2). 

Box 1: BAPEN's 'Malnutrition Universal Screen Tool' (MUST)

  • MUST scores are calculated by looking at a person’s Body Mass Index (BMI) and recent unintended weight loss
  • The risk is ranked as follows: 0 (Low), 1 (medium), 2+ (high)
  • Depending on the risk, interventions are put in place to improve MUST score

For more information see must/must_full.pdf


Box 2: Lifestyle topics

Frailty assessment using the PRISMA Frailty Questionnaire

  • Health background
  • Information on recent hospital admissions -  strength assessment
  • Care and support provision
  • Loneliness and isolation
  • Appetite, chewing and swallowing issues
  • Hydration status and continence issues
  • Oral Nutritional Support (ONS) prescription
  • Mobility issues and recent falls
  • Memory concerns and dementia diagnosis
  • Sensory issues including sight and hearing
  • Practical issues e.g. shopping, access to a computer


Those at risk of malnutrition are offered a bespoke higher energy menu from the meals on wheels service, additional energy-dense and fluid-rich snacks at no additional cost, and those at particularly high risk are offered one to one advice from one of the in-house dietitians. Furthermore, clients may be referred to external services such as lunch clubs, a continence service, or mobile opticians to improve quality of life and address any health concerns. Clients are reviewed regularly to monitor their nutritional status and general wellbeing. 

Results so far

The screening programme commenced in October 2015, and as of August 2016, the team have visited 224 clients across Hertfordshire. The data so far suggest that at the initial point of contact:

  • 33% were at risk of malnutrition
  • 16% had a BMI of over 30kg/m2 indicating they are obese
  • 15% are being prescribed Oral Nutritional Supplements.

Reviews of those at risk are conducted every three months (or earlier if a need is identified) and those at low risk are revisited in six months. Early figures have shown that at the first three month review (37 clients):

  • 43% of clients at risk of malnutrition have improved their MUST scores following intervention
  • 46% had a MUST score which remained stable
  • 11% of clients had a worsened MUST score due to health issues or advancing dementia

Looking forward

The team are continually analysing the effect of the interventions to make improvements. The screening process provides a unique insight into the root causes of malnutrition, allowing for the team to focus on interventions that target some of the most vulnerable groups. For example, education sessions for carers which focus on supporting clients living with dementia to eat well have just been launched, as well as resources to help tackle dehydration (36% of clients screened reported that they had less than the recommended six to eight cups of fluid a day) are currently being developed.

With a food first approach, the team also plans to decrease the reliance on oral nutritional supplements, and reassess frailty status and its link to poor nutrition.

By building stronger links with other health and care providers and support groups, the team hopes to expand and promote a service which looks to take a preventive approach in tackling malnutrition.

For further information on the project please contact the Nutrition & Wellbeing Team at .

Emmy West R. D.
Dietetic and Wellbeing Officer
Hertfordshire Independent Living Service


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