The Skeleton in the Community Wardrobe

In the beginning

In 1974 Charles Butterworth wrote “The Skeleton in the Hospital Closet”, an article referring to the lack of awareness amongst clinicians about the incidence of malnutrition in UK hospitals (1).

It’s astounding to realise that over 40 years later there have been no sustainable solutions to recognising nutrition risk in older people and treating it at an early stage (2).

Paying the price

A 2011 UK study documented the significant cost of malnutrition. Over a 6 month period, the healthcare cost of managing malnourished patients was NZD $3343, more than double the amount of managing non-malnourished patients (NZD $1430) (10) . It’s clear that if you’re malnourished you have a higher risk of developing pressure injuries or falling; costly outcomes for both health services and, more importantly, to the older persons’ health-related quality of life.

The root of the problem

Where Dr Butterworth saw malnutrition as a skeleton in the hospitals’ closet my thoughts are that, in 2018, the skeleton isn’t in the hospital’s closet but in the communities’ wardrobe.  

There’s research confirming better health outcomes for older people who have a higher BMI than recommended for younger adults (3). Our idea of what a healthy weight is needs to change as we age. We live in a society where “slim” and “thin” are sought after goals for younger adults. However, putting these expectations on older adults has serious health and financial consequences for seniors and those caring for them.

In our own backyard

In New Zealand we now have research which confirms what community and residential care dietitians have been observing for years; that is malnutrition and the risk of malnutrition in our senior population starts in the community.

Assessments completed with people who had recently been admitted to hospitals or residential care in Auckland, show a high incidence to people (43%) who were malnourished and an even higher number of older people (47%) at risk of malnutrition (4, 5, 6).

A quick and easy solution

After 40 years of neglect, the good news is we can do something about this under recognised problem hiding in “Community Wardrobes.”

The low cost solution to preventing malnutrition is using simple, validated nutrition and dysphagia risk screening tools.

Depending on where you’re working or who you’re working with, here are some great screening tools to look at:

All these tools are available online, free of charge and can be used with minimal training by all members of the interdisciplinary community or residential care team.

One size doesn’t fit all

Don’t fall into the trap of believing the InterRAI assessment replaces nutrition screening in residential care.  You still need to complete nutrition screening because while the InterRAI assessment asks some nutrition related questions, it is not a validated nutrition screening tool and is only completed six monthly or when a resident’s condition changes significantly.

“At risk” scores from the screening tools described above can be managed through first level intervention and higher risk scores referred for comprehensive assessments with dietitians or speech language therapists. The next blog in this series will cover nutrition interventions and care strategies for people “at risk” of malnutrition or identified as malnourished.  

A challenge to New Zealand

I’m aware of the amount of national funding and energy New Zealand  puts into reducing the risk of falls in older people, yet there is no national initiative set up to identify seniors at  risk of malnutrition or swallowing. Both issues significantly affecting the strength and balance, quality of life and health related outcomes for older people.

Targets are set for health outcomes including smoking cessation and falls prevention, why it is that nutrition risk is given such a low priority for the older person?

What would happen if there were incentives and health targets put in place around screening for the nutritional status of older people – would that be the solution to addressing the current “Skeleton in the Wardrobe” seen across the senior community in New Zealand?

By Kaye Dennison (NZRD)

Learn More: Food for Organisations


  1. Butterworth C.E.Jr., The Skeleton in the Hospital Closet. Nutrition Today: March-April 1974 - Volume 9 - Issue 2 - p 4-8.
  2. Correia MITD., Addressing the Hidden Burden of Malnutrition for Hospitalised Patients. Research Editorial, Journal of the Academy of Nutrition and Dietetics, 2018 Jan; 118(1):37-39.
  3. Caryl A Nowson et al, BMI and all-cause mortality in older adults: a meta-analysis The American Journal of Clinical Nutrition, Volume 99, Issue 4, 1 April 2014, Pages 875–890
  4. Wham, C., et al., Malnutrition risk of older people across district health board community, hospital and residential care settings in New Zealand. Australasian Journal on Ageing, 2017: p. 1-7.
  5. Wham , C., et al., High nutrition risk is associated with higher risk of dysphagia in advanced age adults newly admitted to hospital. Nutrition and Dietetics, 2018, Vol 75 p. 52-58.
  6. Watkin, R.S., et al., Screening for nutrition risk and dysphagia among older adults recently admitted to age related residential care within the Waitemata DHB region, in Annual New Zealand Nutrition Society Conference 2016: Christchurch, New Zealand.
  7. Mini Nutritional Assessment – Short Form – Nestle; accessed 15th January 2018
  8. Keller HH. Goy. R  Validity and reliability of SCREEN II (Seniors in the community: risk evaluation for eating and nutrition, Version II). Eur J Clin Nutr. 2005 Oct;59(10): p1149-57.
  9. Belafsky P, Mouadeb D, Rees C, et al. Validity and reliability of the eating assessment tool (EAT-1). Ann Otol Rhinol Laryngol. 2008; 117(12):919-924.
  10. Guest, J. F., et al., (2011). Health economic impact of managing patients following a community-based diagnosis of malnutrition in the UK. Clinical Nutrition, 30(4), 422-429.  

1 comment

Gwynneth Scott

Great article Kaye I’m going to share with the team here at ADHB
Thanks Gwynneth

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