GUIDELINE FOR NUTRITIONAL SUPPORT FOR ADULTS IN PRIMARY CARE

Transcription

1 GUIDELINE FOR NUTRITIONAL SUPPORT FOR ADULTS IN PRIMARY CARE Applicable to People resides in Greenwich who requires nutritional support Clinicians managing people who requires nutritional support Date ratified 17/11/2015 Next review date 17/11/2017 Clinical Guideline written by Clinical Guideline reviewed by Committee where Clinical Guideline ratified [redacted], Greenwich CCG Dietetic Adviser [redacted], Head of Medicines Optimisation Oxleas Community Dietetic Team Medicines Management Sub-Committee Version Author Date Reason for review Version 1.0 [redacted], senior Dietitian 2004 Version 2.0 [redacted], Highly Specialised Dietitian, Dec 2007 Guideline expired Community Rehabilitation Services Version 3.0 [redacted], Dietetic Advisor Sep 2013 Guideline expired Version 4.0 [redacted], Dietetic Advisor Nov 2015 Summary of change from previous version: 1. Updated products list for OTC and ACBS oral nutritional supplements (ONS) 2. Updated guidelines using generic powder-based and milkshake-based ONS as prices are comparable between products 3. Added cost and nutritional profile for ONS in Appendix 3 4. Added primary care malnutrition service referral pathway in Appendix 4 Acknowledgement: Adapted from work developed by Lewisham Healthcare NHS Trust NHS London Procurement Partnership 1

2 GUIDELINES Contents 1. FOREWORD INTRODUCTION & BACKGROUND NUTRITION SCREENING OPTIMISING MANAGEMENT SPECIFIC ADVICE FOR SPECIAL GROUPS REFERENCES AND FURTHER READING APPENDIX 1: SUMMARY OF GUIDELINES APPENDIX 2: FOOD FIRST LEAFLETS APPENDIX 3: COST OF FREQUENT FIRST LINE SUPPLEMENTS (OCTOBER 2015) APPENDIX 4: PRIMARY CARE MALNUTRITION SERVICE REFERRAL PATHWAY

3 1. FOREWORD A. Guideline Purpose This guideline has been produced to support GPs and healthcare professionals, in primary care, to manage adult patients requiring oral nutritional support. This document is based on the guidelines developed by the London Procurement Programme s Clinical Oral Nutrition Support Project and has been localised for use by GPs and healthcare professionals within Greenwich CCG. The guideline aims to improve patient outcomes through the appropriate screening, assessment and evidence based management of patients, through a strategy of food first and appropriate use of oral nutritional supplements (ONS) in patients who are identified as being nutritionally compromised and meet the Advisory Committee of Borderline Substances (ACBS) indications. The primary care cost of oral nutritional supplements (ONS) in Greenwich in 2014/15 was circa 602, This guideline is the first step in a series of initiatives to redesign the patient pathway across the local health economy. B. Guideline Objectives The objectives include: To promote consistency in screening using a standard tool To ensure patient management is patient centred, clinically appropriate and cost effective To ensure patients achieve optimum nutritional outcomes with appropriate screening, monitoring and support To adopt a strategy of food first in those patients who are identified as requiring nutritional support To ensure the use of ONS is based on best practice evidence and in line with ACBS criteria To ensure healthcare professionals are aware of and implement good prescribing practice for ONS C. Guideline Review This guideline will be reviewed, as and when the patient pathway for nutritional support is redesigned; or within two years (whichever is or sooner). 1 INTRODUCTION & BACKGROUND Nutrition is an essential part of patient care both within the acute and community settings. Malnutrition is estimated to affect at least two million adults in the UK and cost 7.3 billion annually. Malnutrition may occur as a result of illness or from a variety of physiological and social co-factors (Cochrane, 2007). It has a diversity of effects, influencing every system of the body (Stratton et al, 2003). Some adverse effects of malnutrition include: Impaired immune responses - increasing risks of infection Reduced muscle strength and fatigue Reduced respiratory muscle function - resulting in increased difficulties in breathing and expectoration, in turn increasing the risk of chest infection and respiratory failure Impaired thermoregulation - predisposition to hypothermia Impaired wound healing and delayed recovery from illness Apathy, depression and self neglect 3

4 Increased risk of admission to hospital and length of stay Poor libido, fertility, pregnancy outcome and mother child interactions (MAG, 2000) The screening for and treatment of malnutrition is an integral part of patient care. 2 NUTRITION SCREENING Nutrition screening should be standard practice in all inpatient settings (hospitals) and community healthcare settings (GP clinics, care homes) (NICE, 2006). In 2006, the National Institute for Health and Clinical Excellence (NICE) released guidance 32; Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. This document recommends that nutritional support should be considered in people who are malnourished as defined by: BMI less than 18.5kg/m 2 Unintentional weight loss is greater than 10% within the last 6 months BMI is less than 20kg/m 2 and unintentional weight loss is greater than 5% within the last 3-6 months Malnutrition risk is defined as: Have eaten little or nothing for more than 5 days and unlikely for the next 5 days Have poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs e.g. catabolism The malnutrition screening tool used within Greenwich is the Malnutrition Universal Screening (MUST) Tool. The MUST tool was developed by the Malnutrition Advisory Group (MAG) of British Association for Parenteral and Enteral Nutrition (BAPEN). It has been validated for use in the hospital, community and care settings and is the standard screening tool recommended by NICE and available from and available as app for download onto smartphones. The MUST tool is an easy to use, five step tool to identify adults who are malnourished or at risk of malnutrition: Step 1 Step 2 Step 3 Step 4 Step 5 Calculate BMI using patient weight (kg) and height (m) Note percentage weight loss and score using the tables in the toolkit Establish acute disease effect (ADE) and score Add up score from steps 1, 2 and 3 to establish overall risk of malnutrition Develop an individualised care plan based on risk score 3 OPTIMISING MANAGEMENT D. Assess Underlying Cause The underlying cause of malnutrition needs to be clearly identified and appropriately managed as part of the treatment plan this includes both social and disease related causes. See APPENDIX 1: SUMMARY OF GUIDELINES. E. First Line Dietary Advice Dietary counselling to encourage the use of energy and protein rich foods should be recommended as the initial intervention before prescribing ONS with the following being encouraged: Little and often have nourishing snacks or drinks between meals and eat regularly throughout the day Enrich foods and drinks such as cereals, milk, soup, mashed potato 4

5 Encourage use of full fat milk and aim for an intake of one pint a day Drink more milk based drinks rather water, tea or coffee (or make the latter with milk) Avoid low fat, low sugar products as they are unsuitable during this period of illness Leaflets APPENDIX 2: FOOD FIRST LEAFLETS to help patients with food fortification are also available on the Greenwich CCG Medicines Management website. Patients may be reluctant to eat high fat/sugar foods, so it is important to reinforce the message that the dietary needs of the malnourished are different from that of the healthy population (i.e. healthy eating messages do not apply). Patients should be advised on the treatment goals and monitoring plan (e.g. improve nutritional status, to reach or maintain an agreed weight). F. Over the Counter ONS Over the counter (OTC) oral nutritional supplements are readily available from supermarket or pharmacy counter. They may be used alongside first-line dietary advice prior to commencing prescribed ONS. They are also suitable for patients who do not fall within ACBS recommendations but would like to fortify their diet Examples of OTC supplements: Meritine Energis (powder in sweet, savoury or neutral flavours) Complan (powder in sweet, savoury or neutral flavours) Nurishment (ready made in sweet flavours) Nutrimen (ready made in sweet flavours) Friji, Yazoo, Weetabix drinks G. Prescribing Recommendations for ONS The use of ONS should ONLY be considered when first-line dietary measures (and OTC ONS) have failed to improve nutritional status and/or treatment goals after one month. This guideline should be used to identify patients eligible for ONS. Patients should be advised why they are receiving ONS and that the prescription will be reviewed regularly and is intended as a temporary supplement to oral intake. The ACBS recommends products on the basis that they may be prescribed for the management of specific conditions. Doctors and non-medical prescribers should satisfy themselves that the products can safely be prescribed, that patients are adequately monitored and that, where necessary, expert dietetic or hospital supervision is available. See BNF A2 Borderline Substances for guidelines on prescribing borderline substances and descriptions of the products that can be prescribed. Ensure that the patient s condition falls into one of the following ACBS categories for prescribing ONS: Short bowel syndrome Proven inflammatory bowel Intractable mal-absorption Following total gastrectomy Pre-operative preparation of patients who are Continuous ambulatory peritoneal dialysis undernourished (CAPD) Dysphagia Disease-related malnutrition Bowel fistulas Haemodialysis If a patient does NOT meet the above criteria then OTC supplements should be recommended 5

6 ONS are available in a variety of forms: Powdered supplements Ready to drink - milk based Available in sachets Should to be mixed with full fat milk Some products can be used in cooking e.g. adding to sauces/cereals/ desserts Gluten free Milk shake style Yoghurt flavoured style Pudding style Pre-thickened for dysphagia Preparations containing fibre available Savoury products are available but limited choice and tend to be less popular with patients Gluten free May not be lactose free Tend to be nutritionally complete Ready to drink - juice based Range of flavoured juices Not suitable as first line choice for patients with diabetes Not nutritionally complete Gluten free Lactose free High-energy high protein Low volume therefore suitable for patient who are on restricted fluid e.g. heart failure or patients who are having difficulty with large volume 1. It is important to establish patient preference. It is, therefore, recommended that the initial prescription length should be restricted to one week. Starter packs (where available) provide a useful way of establishing patient preference. Some manufacturers provide free starter packs; others may be prescribed on FP10. This approach will avoid wastage resulting from prescriptions for products that the patient will not take. 2. ONS prescriptions should be for 1.5 kcal/ml or higher calorie products. 1.0 kcal/ml ONS should NOT be prescribed as it is not clinically effective. See Appendix 3 for comparison data for different ONS products. 3. ONS prescriptions should be twice daily to provide an additional kcals/day. Once daily prescriptions only provide half this calorific amount which can easily be met with foods (e.g. enriched milk). Patients often fail to adhere to three times a day and this can lead to wastage. 4. ONS should NOT be prescribed as the sole source of nutrition unless under the supervision of a dietitian. 5. Include clear directions on the prescription (e.g. twice a day, taken between meals) and avoid prescribing as take as directed. 6. Once ONS preference has been established, prescription length may be increased to 28 days. It is recommended that ONS are prescribed as acute prescription to promote patient follow up 7. It is recommended that the maximum number of flavours prescribed is limited to 3 per prescription. This approach will help to manage prescription fees as a fee is paid for each flavour dispensed. Flavours can be varied to avoid taste fatigue. 8. Prescriptions for ONS must be endorsed ACBS. 9. The following approaches can help to improve adherence, and likelihood of a successful outcome: Explain the need for, and importance of, taking the recommended dose as explained. Provide written information. Serving drinks at preferred temperature and in preferred presentation (e.g. chilling sweet drinks and using a glass or straw). ONS are taken between meals NOT as a meal replacement. Varying the flavours of ONS will help combat taste fatigue. Maintaining good oral hygiene / care. 6

7 H. Monitoring 1. Prescribers or dietitians should monitor patients monthly for the first 3 months. Ideally this will be before a prescription is issued. Patients established on ONS should be reviewed every 3-6 months. 2. The purpose of monitoring is to assess if the aim of therapy is being met and progress towards treatment goals. 3. Monitoring should be both quantitative and qualitative and should include: Weight* and BMI Changes in dietary intake Adherence with ONS and stock levels at home * If unable to weigh the patient, use other subjective measures to assess if weight has changed include looking at the patient s appearance, asking about fit of clothes / watches / belts / rings. In addition, mid upper arm circumference may be measured 4. A record of their intake will help to indicate if the patient has increased their nutritional intake. If food fortification has been used they patient may not be eating larger amounts but the nutrient density of their food has improved. 5. The opinion of carers and relatives is helpful in assessing if improvements have been made with the dietary input. 6. When the agreed treatment goals are achieved, ONS should be discontinued gradually over 1 2 months. At least one review following the termination of ONS is required to ensure that there is no recurrence of the precipitating problem. This follow up should be within 3 months of the patient stopping. 7. If the treatment goals are not being met while taking ONS as recommended the reasons must be reviewed and ongoing need for ONS assessed. It is recommended to review the underlying cause and refer to a dietitian. 8. Should the patient wish to continue taking ONS and it is no longer indicated by ACBS criteria, recommend the use of OTC supplements. It is NOT appropriate to continue ONS prescriptions. I. Referral to a Dietitian 1. Dietetic referral is appropriate for patients who a. have a high nutrition screening score (MUST score of 2 or above), or b. have been prescribed of ONS products, or 2. Dietetic referral should be carried out for patients who have a MUST score of less than 2 and a. have a co-existing medical conditions such as malabsorption; severe renal or hepatic insufficiency; coeliac disease; complex or unstable diabetes and cardiovascular disease, Parkinson s Disease, dementia, stroke and HIV where the patient is not already under the care of a multi-disciplinary specialist service, or b. nutritional status has deteriorated despite supplementation (and the patient is adhering to recommended regimen) - refer after one month c. have not responded, within 3 months, to a food first strategy plus ONS (and is adhering to recommended regimen) 3. Where swallowing difficulties or other indications for texture modified diet exists consider referring to Speech and Language Therapist. 4. Dietetic arrangements is now in place for GPs to refer provided the following information is included in the referral form Weight BMI MUST score Co-morbidities and other relevant social factors Confirmation that food fortification, OTC supplements and ONS have been tried 7

8 5. Clinicians are advised that hospital dietitians requesting that a patient continues on ONS post discharge must: Provide details of nutrition intervention undertaken Give ACBS indication for ONS prescription Identify aims of treatment including estimated length of ONS prescription Provide ONS prescription dose details Provide details of planned review and by whom (e.g. hospital dietitian, community dietitian, GP) Refer to Community Adult Dietitians for review In the absence of any written correspondence, patients should only be given one month s prescription for ONS and then reassessed using the MUST tool. The flow chart in Appendix 3 should then be used to inform the on-going need for treatment. 5. SPECIFIC ADVICE FOR SPECIAL GROUPS This section provides specific advice on managing patients falling into the following special groups should be monitored regularly by a specialist dietitian from primary and secondary care dietitians: Patients with diabetes and/or cardiovascular disease (including hyperlipidaemia) Patients in Care Homes Palliative care Substance misuse 5.1 Diabetes and Cardiovascular Disease (including hyperlipidaemia) 1. Dietary advice for malnutrition may conflict with recommendations for the dietary management of diabetes and high cholesterol. 2. Priority to addressing malnutrition should be considered in such patients. 3. If malnutrition risk is considered to be the greatest health risk in the short term, manage the malnutrition by diet and manage glycaemic control and/or blood lipids by medication if indicated. 4. Tighter monitoring of blood glucose levels is recommended for patients with diabetes. It is desirable to keep the blood glucose levels in a reasonable range to prevent undesirable side effects. Diabetes medications may need to be reviewed if oral intake has changed significantly. 5. In diabetics, if ONS are indicated, chose milky based products rather than juice based (due to lower glycaemic index (GI) value). 6. A preference for heart healthy fats (e.g. unsaturated fats from plant origin in preference to those with a high saturated fat content) should be encouraged for patients with raised cholesterol. Healthier choices to increase the overall caloric value of the diet include using margarine (either a polyunsaturated e.g. sunflower oil based; or a monounsaturated e.g. olive oil based product is recommended), nuts and seeds, avocados, hummus and plants oils (with the exception of palm and coconut oil). 7. Consideration must also be given to the cholesterol level and associated risk it poses to the patient if saturated fat in the diet is increased. 5.2 Patients in Care Homes 1. The Department of Health s National Minimum Standards for Care Homes for Older People (2003) and NICE 2006 state that new service users must be weighed on admission, and that their diet and dietary preferences must be assessed and recorded. 2. All care home residents should have their nutritional status screened, using MUST on a monthly basis. A record should be maintained on nutritional status (weight record) and intake (food charts) in order to help monitor changes. 3. Patients triggering a MUST score of greater than 2 should follow the pathway set out in Appendix 1. As with other patients, an individualised treatment plan should be determined. This should be 8

9 documented, along with details of any interventions taken. It is recommended that this is kept with the records of the patient s nutritional status and intake. 4. Food first, using high energy and protein food choices, together with food fortification should be promoted first line. ONS must NOT be used as a substitute for the provision of food. 5. Any patients taking ONS should have a food and fluid chart. 6. It is recommended that ONS, if used, are prescribed on the medicine administration record (MAR) and a record of administration made. A record of whether patient has taken the supplement should be kept on the food and fluid chart. 7. ONS should not be pooled or shared between patients within Care Homes. Prescribing for individual patients, recording them on the MAR chart and ensuring that the supplying pharmacist labels the products for individual patients will help to discourage this inappropriate practice 5.3 Palliative Care 1. Consideration must be given to the patient s prognosis and their quality of life. 2. Nutritional supplement usage is common among palliative care patients, however the rationale and purpose of such a prescription needs to be carefully considered. Avoid prescribing ONS for the sake of doing something especially if other dietary treatments have failed. 3. At the end stages of life, weighing the patient is not indicated and the nutritional content of the meal is no longer of prime importance. Instead consider the patient s quality of life and encourage patients to have small frequent meals and chose their favourite foods. Underlying symptoms such as nausea, vomiting and constipation may negatively affect oral intake and should be managed. 5.4 Substance Misuse 1. ONS prescribing in substance misusers (alcohol and drug misuse) is an area of increasing concern, due to both the cost and the question of appropriateness and compliance. There is also evidence of misuse of ONS by patients falling into this group. 2. Substance misusers may have a range of nutrition related problems such as: Poor appetite and weight loss Nutritionally inadequate diet Constipation (drug misusers in particular) Dental decay (drug misusers in particular) 3. Reasons for nutrition related problems include: Drugs themselves can often cause poor appetite, reduce ph of saliva leading to dental problems, constipation, craving sweet foods Chaotic lifestyles Lack of interest in food and eating Poor dental hygiene (drug misusers in particular) Irregular eating habits Poor memory Poor nutrition knowledge and skills Low income, intensified by increased spending on drugs or alcohol Homelessness / poor living accommodation Poor access to food Infection with HIV or hepatitis B and C Eating disorders with co-existent substance misuse 4. Problems often created by prescribing ONS in Substance Misusers: Once started on ONS it may be difficult to stop the individual taking them ONS may be taken instead of meals and therefore no benefit They may be given to other members of the family / friends They may be sold and used as a source of income 9

10 Patients can be poor clinic attendees therefore making it difficult to weigh them and re-assess need for ONS 5. Substance misuse is NOT a specified ACBS indication for ONS prescription. ONS should NOT be prescribed in substance misusers unless ALL the following criteria are met: BMI<18kg/m 2 AND there is evidence of significant weight loss (>10%) AND there is a co-existing medical condition which could affect weight or food intake AND once nutritional advice has been advised and tried AND ideally the patient is in a rehabilitation programme e.g. methadone or alcohol programme or on the waiting list to enter a programme 6. OTC supplements are recommended first line or for individuals who, do not meet the criteria, but are insistent on using a high energy supplement. 7. If ONS are initiated The patient should be assessed by a dietitian if they don t respond to other measures and commit to attending appointments. If they fail to attend on any occasion, ONS should be discontinued and the patient will be discharged (unless there is a good reason for the DNA). Maximum prescription should be for 600 kcal/day (twice daily) unless otherwise specified by a dietitian Issue acute prescriptions only and avoid putting ONS onto repeat prescriptions The should be prescribed on a short term basis only (i.e. 1-3 months) If there is no change in weight after three months, ONS should be reduced and discontinued If weight gain occurs, continue until usual weight or healthy weight is reached, and a strategy to reduce ONS agreed with the patient 6. REFERENCES AND FURTHER READING British National Formulary October Council of Europe Report on nutrition, food safety and consumer protection, 2003 Department of Health, Better Hospital Food, 2010, Department of Health, Essence of Care, 2003, Department of Health, National Minimum Standards for Care Homes for Older People, 2003, Malnutrition Advisory Group (MAG), British Association of Parenteral and Enteral Nutrition NICE Clinical Guidance 32, Nutrition Support in Adults, February NICE Quality Standard 24 Nutrition Support in Adults, November

11 APPENDIX 1: SUMMARY OF GUIDELINES TREAT & FOLLOW UP A STEPWISE APPROACH TO NUTRITION SUPPORT Patient identified as requiring oral nutrition support (MUST Score 2) Address underlying causes & set goals for management First line Food First dietary advice Provide 100 Kcal Booster and Fortified Diet Plan diet sheets as appropriate Patient identified via nutrition screening tool as requiring oral nutrition support Review after ONE month or sooner depending on clinical needs Assess weight, dietary intake, adherence with Food First approach IMPROVEMENT NO IMPROVEMENT Weight stable or increasing / appetite improved Reinforce advice Reassess after one month Goals met? Continue to monitor for 3 months Goals NOT met? Use Clinical Judgement & Refer to Dietitian sooner if patient has MUST score of 2 AND: Co-existing medical condition e.g. malabsorption, severe renal or hepatic insufficiency, coeliac disease Dysphagia or indication for texture modified diet (refer to SALT) Patients who have historically been on ONS for longer than 3 months Refer to Acute Trust Dietetic Dept. Still losing weight / appetite poor Reinforce advice Reassess underlying problems and manage Continue dietary measures AND: Yes Can patient tolerate milk and mix a shake? Yes A cost effective powder product 1 twice a day ACBS criteria met? OTC supplement e.g. Complan, Meritine Energis No No A cost effective milkshake products 1 twice a day If milk intolerant refer to dietitian Refer to Appendix 3 for products Reassess after 1 month - check o Weight and BMI o Dietary intake o Adherence and patient s stock levels of ONS (where applicable) Tailor ONS prescription if necessary For housebound patients with a MUST score 2 Refer to the Community Assessment & Rehabilitation Dietitian Contact number: Goals met within 3 months. Reduce & stop ONS Patient deteriorating (after 1 month); OR Goals NOT met within 3 months 11

12 SCREENING What you MUST do MUST - 5 simple steps to assess overall risk of malnutrition Step 1 Calculate BMI using patient weight (Kg) and height (m) Step 2 Note % weight loss and score using the tables in the toolkit Step 3 Establish acute disease effect (ADE) and score Step 4 Add scores from steps 1, 2 and 3 = overall risk of malnutrition Step 5 Develop individualised care plan based on risk score MUST Have Calculator iphone App ASSESS & ACT On the underlying cause Medical condition causing poor appetite, oral intake, nausea Management by GP, District Nurse, Community Matron Medication for underlying condition Poor emotional or mental health e.g. depression, bereavement, isolation GP management, counselling, social clubs, day centres, Community Psychiatric Nursing Poor dentition Refer to Dentist Advise on soft / appropriate diet Swallowing difficulties Refer to Speech & Language Therapist Patients with specific / complex conditions e.g. malabsorption, renal or hepatic insufficiency Refer to dietitian as specialised products may be required Unable to do own shopping; or cook / feed self Social Services / Carers / Friends / OT Home delivery, meals on wheels Financial Difficulties; or High Alcohol intake; or Substance Misuse Refer to Social Services Benefits / allowances review 12

13 Malnutrition Deficiency or imbalance of nutrients, protein or energy which has an impact on body function or clinical outcome Defined as: BMI less than 18.5kg/m 2 ; or Unintentional weight loss >10% within the last 6 months; or BMI less than 20kg/m 2 and unintentional weight loss >5% within the last 3-6 months Malnutrition risk defined as: Eaten little or nothing for > 5 days and unlikely to for the next 5 days Poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs e.g. catabolism More hospital admissions / re-admissions Increased length of stay in hospital Vulnerability to illness & complications Consequences of malnutrition Reduced Independence More GP visits, care at home, antibiotics Poor outcomes & mortality 3 Steps to Optimising Outcomes Screen & Assess Treat Follow up Screen patient using MUST tool See panel (on right) for 'who's at risk' See flow chart (Page 3) for advice on referral Individualised patient treatment plan and goals 'Food first' approach Help with food (e.g. family, carer, social support) Consider ONS if ACBS criteria apply See 'Top Tips for Prescribing' (Page 4) Follow up progress against treatment plan Assess adherence Tailor / stop intervention depending on progress) Refer to dietitian if... see flow chart page 3 Who s at risk? Long Term Conditions e.g. COPD, cancer, Inflammatory Bowel Disease, GI disease, renal or liver disease Chronic progressive disease e.g. dementia, neurological conditions including Parkinson s Disease, Motor Neurone Disease Debility e.g. frailty, immobility, old age, depression, recent hospital discharge Social issues e.g. poor support, housebound, inability to cook and shop, poverty Acute Illness & no food eaten for 5 days (rare in the community) Read on for more advice on Screening, Assessment, Referral, Treatment & Follow up 13

14 TOP TIPS FOR PRESCRIBING 1. Encourage a high energy diet and food fortification (provide Food First and Nourishing Drinks leaflets) prior to considering supplements; and whilst patients are taking supplements. Address social factors e.g. help with food, dental issues etc 2. Patients should be informed why they need Oral Nutritional Supplements (ONS) and the desired outcome 3. ONS should be given in addition to meals and not in place of a meal. They should not be taken less than an hour before a meal as they can reduce appetite 4. Aim to prescribe 2 ONS products a day (instead of 3) to aid adherence. It is better for a patient to finish 2 ONS than only half finish 3 5. Prescribe feeds that contain a minimum of 1.5kcal/ml. Avoid 1kcal/ml products as they are more expensive/kcal, and require a larger volume to be consumed to meet nutritional goals 6. Aim to use a fibre enriched product if the patient is constipated or has a tendency to constipation. Two fibre enriched feeds per day will provide ⅓ of the fibre requirements 7. Supplements are available in a range of flavours and types including milky, yoghurt style, fruit juice based and dessert style. The first prescription should be for one week s supply of mixed flavours and types to help identify patient preferences. Starter packs are useful for this purpose (although these are only available for sip feeds ) 8. Limit the number of flavours to a maximum of three on any prescription (flavours can be varied to avoid taste fatigue ) 9. Monitor patients on a monthly basis to assess progress and tailor or stop prescription in line with the treatment plan Weight and BMI - if unable to weigh the patient, use other measures to assess if weight has changed (e.g. mid upper arm circumference, clothes or rings looser/tighter, visual assessment) Changes in dietary intake has intake improved since feeds prescribed? Are there barriers to dietary change? Adherence is the patient following food first recommendations? Are they adhering to the prescribed ONS regimen? How much stock do they have left at home? 10. When stopping, ONS should be gradually reduced over one to two months (depending on the number of ONS the patient is taking) once the aim of therapy has been achieved. This is to ensure patients are able to manage without them and maintain their nutritional status 11. Use clinical judgement and refer to dietitian if they have a MUST score of 2 AND one or more of the following: Co-existing medical condition e.g. malabsorption, severe renal or hepatic insufficiency, coeliac disease, complex or uncontrolled diabetes or cardiovascular disease (and not under specialist services) Nutritional status deteriorating on food first and ONS (refer within 1 month) or treatment goals not achieved within 3 months Patients historically requiring ONS for more than 6 months Refer to Speech & Language Therapist if patient has dysphagia or indication for texture modified 14

15 APPENDIX 2: FOOD FIRST LEAFLETS diet 100 Calorie Boosters These boosters are approximately 100 calories each and can be added to any appropriate meal or eaten alone. (Please note tbsp = tablespoon tsp = teaspoon). Savoury Toppings Medium spread peanut butter (16g) 1 level tbsp mayonnaise (15g) Average serving salad cream (30g) 2 tbsp hummus (50g) 1 heaped tbsp pesto (20g) Sweet Toppings 1 heaped tbsp sugar (25g) 2 heaped tsp honey (35g) 2 heaped tsp golden syrup (35g) 2 heaped tsp lemon curd (35g) Fruit & Nuts A small handful of peanuts (30g) 5 brazil nuts (15g) A small handful cashew nuts (20g) 1 banana (100g) 5 dried apricots (50g) 6 prunes (60g) 2-3 dates (40g) 1 heaped tbsp sultanas (35g) Dairy 3 tbsp skimmed milk powder (27g) 150ml full fat milk (blue top) 1 scoop ice cream (60g) 75ml evaporated milk 30ml condensed milk 1 small pot full fat yoghurt 30ml coconut cream 1 medium slice of cheddar cheese Snacks 2 digestive biscuits 5 jelly babies 2 fingers of KitKat ½ a Crunchie 1 Fudge bar Bag of crisps 15

16 Fortified Diet Plan The following dietary changes can be tried to help prevent weight loss and encourage weight gain. Discuss with your Nurse/Healthcare professional which options to try. Eat little and often : try small, nourishing meals, snacks and drinks every 2-3 hours throughout the day Use full cream milk: aim for 1 pint / 600mls per day Fortify your milk: add 2-4 heaped tablespoons of dried skimmed milk powder to 1 pint full cream milk and blend/mix until smooth. Chill in the fridge and then use on cereals, in porridge, to make up sauces, soups, desserts, jellies or milky drinks etc. Add dried skimmed milk powder directly to soups, milk puddings, custards, mashed potatoes: try adding 2-3 teaspoons per portion of food Choose full fat and full sugar* products rather than diet reduced/low fat low sugar or healthy eating varieties as these provide more calories Add knobs of butter, margarine**, vegetable oil, rapeseed oil, or olive oil to vegetables, mashed potato, jacket potato etc. Add grated cheese to soup, mashed potato, scrambled eggs etc. Serve main meals with a creamy sauce e.g. cheese, parsley or white sauces Add cream or evaporated milk to soups or puddings e.g. stewed / canned fruits, custard, rice puddings etc and add sugar* to cereals, drinks, desserts. Serve milk or bread puddings with jam, honey or syrup. Have snacks between meals and at bedtime. Try toast with butter and jam, a cheese sandwich, cereal with milk, creamy or Greek yogurt, cake, biscuits, full fat mousse, cream cheese and crackers, dried fruit and nuts, or try a nourishing drink A little alcohol before a meal can stimulate appetite, but check with your GP or pharmacist first if you take any medications For a balanced diet choose a wide variety of foods. At each meal try to have a protein food (meat, fish, egg, cheese, milk, vegetarian alternative, e.g. Quorn, soya, beans or lentils) and a starchy food (bread, cereals, potato, rice, pasta). Eat fruit and vegetables every day puree or take as juice if easier Have plenty of nourishing fluids: aim for 8 glasses (i.e. at least 1.6 litres) a day. Try sweetened fruit juice*, chilled or warmed fortified milk, coffee, hot chocolate or malted drinks made with all milk (fortified) or milk shakes. Choose drinks with high sugar content e.g. fruit juice, lemonade, full sugar squash* 16

17 * If you have diabetes Continue to choose sugar free drinks You can have a moderate amount of sugar containing foods Contact your Nurse or GP if your blood sugars are high or you have sugar in your urine ** If you have high cholesterol or heart disease Try and choose healthy fats from plant sources These include margarine such as sunflower oil or olive oil based, nuts & seeds, avocados, hummus Contact your Nurse or GP if you have concerns such as continued weight loss, difficulty taking solids, worsening appetite, limited food variety How to fortify some common foods Here are some examples to show how easy it is to fortify your diet: Please note tsp = teaspoon / tbsp = tablespoon 1 tbsp dried skimmed milk powder (9g) = 30kcal and 3.3g of protein 1 tsp dried skimmed milk powder (3g) = 10kcal and 1.1g of protein 1 tsp sugar (5g) = 20kcal and 0g of protein 1 heaped tsp honey (17g) = 50kcal and 0g of protein 1 tsp butter or margarine (5g) = 35kcal and 0g of protein 10g cheddar cheese = 42kcal and 2.5g of protein 1 tsp double cream (10g) = 50kcal and 0.2g of protein 2 large dates (40g) = 108kcal and 1.3g of protein Scrambled egg with whole milk (120g) Before fortification: 308kcal and 13.1g of protein. Add 1 tsp butter, 2 tsp of dried skimmed milk powder and 45g of cream cheese: 603kcal and 15.8g of protein Porridge with whole milk (150g) Before fortification: 170kcal and 7.2g of protein. Add 2 tsp of dried skimmed milk powder, 1 tsp of double cream, 1 tsp of sugar and 2 chopped dates: 368kcal and 10.9g of protein Before fortification: 142kcal and 4.7g of protein. Add 2 tsp of dried skimmed milk and 2 tsp of double cream: 262kcal and 7.3g of protein White sauce with whole milk (30g) Before fortification: 45kcal and 1.3g protein. Add 1 tsp of double cream, 2 tsp of dried skimmed milk powder and 10g of cheddar cheese: 157kcal and 6.2g of protein Boiled Carrots (30g) Before fortification: 7kcal and 0.2g of protein. Add 1 tsp of butter and 2 tsp of honey: 90kcal and 0.2g of protein Mashed Potato (60g) Before fortification: 62kcal and 1.1g of protein. Add 1 tsp butter, 2 tsp of dried skimmed milk powder and 1 tsp of double cream: 170kcal and 3.5g of protein Adapted, with permission from South Essex Partnership University NHS Foundation Trust Leaflet, for use in Greenwich 17

18 APPENDIX 3: COST OF FREQUENT FIRST LINE SUPPLEMENTS (OCTOBER 2015) A. Benefits of changing from 1kcal/ml products to 1.5kcal/ml products 1kcal/ml Products 1.5kcal/ml Products Cost Savings (per patient /yr) Ensure tds = 6.78 (3 x 250ml cans provide 750kcals 24gm protein) Fresubin Original tds = 6.36 (3 x 200ml cartons provide 600kcals 22.8gm protein) Ensure Plus bd = 2.80 (2 x 220ml cartons provide 660kcals 27.6gm protein) Fresubin Energy bd= 2.96 (2 x 200ml cartons provide 600kcals 22.4gm protein) B. Comparison of cost effective powder-based products Product Unit Nutritional Profile Cost per Unit (without milk) Foodlink Complete 57g to be mixed with 200ml whole milk kcal g protein g (vanilla) to be mixed with 200mls whole milk Aymes Shake 57g to be mixed with 200ml whole milk 15.6g protein Ensure Shake 57g sachet to be mixed with 200ml 389kcal 0.78 whole milk 17g protein Fresubin Powder Extra 62g sachet to be mixed with 200mls 397kcal 0.80 whole milk 17.7g protein Complan Shake 57g sachet to be mixed with 200mls 387kcal 0.78 whole milk 15.6g protein Enshake 96.5g sachet to be mixed with 240mls 600kcal 2.16 whole milk 16g protein Calshake 87g sachet to be mixed with 240mls 605kcal 2.36 Scandishake whole milk 85g sachet to be mixed with 240mls whole milk C. Comparison of cost effective milkshake products 12g protein kcal g protein 2.41 Supplements Unit Nutritional Profile Cost per Unit Aymes Complete 200ml bottle 300kcal g protein Nutriplen 125ml bottle 300kcal g protein Fresubin Energy 200ml bottle 300kcals

19 11.2g protein Resource Energy 200ml bottle 300kcals 11.2g protein Fortisip Compact 125ml bottle 300kcals 12g protein Ensure Plus 220ml bottle 330kcals 14g protein Ensure Compact 125ml bottle 330kcals 13g protein Fortisip Bottle 200ml bottle 300kcals 12g protein Ensure Twocal 200ml bottle 399kcal 16.8g protein D. Comparison of low volume, high energy products Product Unit Nutritional Profile Cost per Unit Nutriplen Protein 200ml bottle 300kcal g protein Fresubin 2kcal 200ml bottle 400kcal g protein Fortisip Compact Protein 125ml bottle 300kcal g Fresubin Protein Energy 200ml bottle 300kcal g protein Ensure Plus Advanced 220ml 330kcals g protein Fortisip Extra 200ml bottle 320kcal 20g protein 2.14 E. Comparison of ONS vs. OTC Supplements / Food Items Nutrition Supplement Drinks on prescription Protein (g) Energy (Kcal) Over the counter alternative Protein (g) Energy (Kcal) Ensure Plus (220mL) Complan made with full cream milk (200mL) Fortisip (200mL) Build up made with full cream milk (~200mL) Fresubin Energy (200mL) Nourishment 1/2 can (210mL) Resource Energy (200mL) Banana Smoothie (~250mL) F. Comparison of Food vs. Alternative / Fortified Food Options Food Item Alternative Option Difference 1 cup semi skimmed milk 1 cup full cream milk (FCM) Extra 50 kcal per serving 1 cup water 1 cup fruit juice Extra 58 kcal & 1g protein per serving 19

20 1 small packet of crisps Handful of peanut and raison Extra 11 kcal & 4g protein per serving mix 1 scoop mashed potato with 1 scoop mashed potato with Extra 103 kcal & 6g protein per serving margarine margarine, FCM and grated cheese 2 rich tea biscuits 2 chocolate digestives Extra 102 kcal & 1.2g protein per serving G. Comparison of OTC ONS products Supplements Unit Nutritional Profile Meritine Energis 30g serving with 200ml semi skimmed milk 200kcal 16g protein Complan Original 55g serving with 200ml semi skimmed milk 243kcal 8.5g protein Nurishment 400g can 396kcals 20g protein 20

21 APPENDIX 4: PRIMARY CARE MALNUTRITION SERVICE REFERRAL PATHWAY Housebound District Nurse / Care Home COMMUNITY DIETITIAN ALARM Symptoms Anaemia (iron deficiency) Loss of weight Anorexia Recent onset of progressive symptoms Melaena / haematemesis Swallowing difficulty FP10 request Food First if not improved prescribe sip feed Food First if not improved prescribe sip feed GP Practice nurses MUST 2 Nutritional supplement review IBS with no ALARM Symptoms Coeliac disease Pre-bariatric surgery BMI>40 or >35 with co-morbidity Review and consider Food First if not improved prescribe sip feed Patient FP10 request Hospital 21