Birmingham Community Nutrition MUST * screening & the next steps

Transcription

1 Birmingham Community Nutrition MUST * screening & the next steps The identification of undernutrition and the management of oral nutrition support for adults in the community Date of Production: December st Revised draft: June 2013 Final version: December 2013 Issued: January 2014 Review Date: 3 years from date of issue Written by Birmingham Community Nutrition & Dietetic Service This user guide replaces Guidelines for the Management of Undernutrition in the Community * Malnutrition Universal Screening Tool

2 Title MUST screening & the next steps 1 Edition: 3 rd Edition 2 Impact Assessments and Dates: Equality & Human Rights Analysis 25/07/ Approval History: BAPEN 31/01/12 Birmingham & Solihull Cluster MMC 29/05/12 Ratified by BCHC Adults & Communities Quality, Governance & Risk Committee 21/01/ Name of Executive Director Lead: Sarah Monk, Joint Head of Service, Birmingham Community Nutrition, BCHC 5 Name of Lead Officer: Janet Gordon, Team Leader, Nutrition Support Team, Birmingham Community Nutrition 6 Date Issued: January Review Date: 3 Years from date of Issue 8 Target Audience: External organisations such as GP practices, care homes (residential and nursing) pharmacists 9 Is this policy new or a replacement for existing policies? 10 If no, which policies should be removed from the intranet? Replacement Guidelines for the management of undernutrition in the community 11 Type of policy please circle Clinical 12 Summary The timely identification of undernutrition and evidence based management of oral nutrition support in the community are essential in improving health and aiding recovery from illness, and in ensuring the most efficient use of resources. This policy aims to give guidance to all staff on how to use the nationally validated MUST screening tool and how to implement effective care planning based on the MUST score.

3 CONTENTS PAGE Introduction 2 The five steps of MUST 4 MUST flow charts and record chart 5 Implementation of the care plans including first line advice 8 Prescribing nutritional supplements 11 Withdrawing nutrition support 14 Palliative/end of life care 15 Recommended resources 16 References 17 Referral Process and How to Contact a Dietitian 18 Appendix 1 MUST reference charts 19 Appendix 2 Care plans for care homes 25 Appendix 3 Care plans for community care 27 Appendix 4 Identifying underlying causes of nutritional deficiencies and action plans 29 Appendix 5 Boosting the calories recipe adapting 31 Appendix 6 Increase the calories 32 Appendix 7 Types of first line nutritional supplement 33 Appendix 8 Dietetic referral criteria 34 Appendix 9 Dietetic referral form 35 Appendix 10 Subjective indicators of malnutrition 37 Appendix 11 Special considerations for ONS prescribing: substance misusers 38 The Malnutrition Universal Screening Tool ( MUST ) is reproduced within these Guidelines with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). (Thank you to C.A. Russell of BAPEN who provided feedback and recommendations on the content of this document). Please note: This user guide is intended as guidance only and healthcare professionals remain responsible for the care given to their patients. The contents reflect evidence or consensus opinion. It is the responsibility of the healthcare professional to ensure that they keep up to date and that new information, evidence, consensus or national guidelines are taken into account when giving advice and when recommending or prescribing oral nutritional supplements. This user guide is intended for use with individuals who have the ability to eat and drink safely (with the use of modified consistencies where appropriate) and are not intended for use with individuals who have been advised to be nil by mouth. The suitability of enteral feeding should be considered, where appropriate, for individuals who are nil by mouth, but whose gastrointestinal tract functions, and this should be a multidisciplinary decision. 1

4 INTRODUCTION Who is this guidance for? GP s and practice staff, case managers, care home staff, and all other healthcare staff who are involved in the care of adult patients (16 years+, excludes those with learning disabilities) in their own homes or in care home beds (BCHC healthcare staff please refer to the BCHC MUST Policy) Why is guidance required? Early identification and appropriate management of patients with poor nutritional status, or who are at risk of malnutrition, will allow the most efficient use of resources and will increase health benefits and recovery. This guidance supports the national QIPP Safe Care Work Stream 1 and the Care Quality Commission outcome 5 Meeting Nutritional Needs Standard. Within the community setting a coordinated approach by a range of health care professionals is essential to identify, treat and monitor patients who are malnourished or at risk of becoming so. This guidance, based on the NICE guideline for Nutrition Support in Adults (2006) 2 and the National Prescribing Centre s Prescribing of adult oral nutritional supplements (2012) 3, sets out the processes required to identify these patients and will enable health care professionals to identify, treat, monitor and review patients who are malnourished or at risk of becoming so. It will also assist health care professionals to refer onto specialist services when appropriate to do so, and ensure that nutritional supplements are not inappropriately prescribed. What is malnutrition? Malnutrition is defined as a state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients, causes measurable adverse effects on tissue/body structure and function and clinical outcome 4. For the purpose of these guidelines the term malnutrition will refer to a deficiency of energy, protein and/or micronutrients. The main causes of malnutrition 2 are:- y Impaired intake y Impaired digestion and/or absorption y Altered metabolic requirements y Excess nutrient losses If untreated, malnutrition has many consequences detrimental to physical function, disease outcomes and psycho-social wellbeing as well as healthcare costs. Examples are:- y Increased admissions and re-admission to hospital y Increased length of hospital stay y Increased visits to GP y Increased mortality y Inability to cope with ill health resulting in a loss of independence and well being In 2011 the cost in the UK was estimated to be over 13 billion a year 5. 2

5 How is malnutrition identified? The Malnutrition Universal Screening Tool ( MUST ) has been designed to enable identification of adults who are malnourished or at risk of malnutrition, as well as those who are overweight or obese. MUST has not been designed to identify deficiencies in or excessive intakes of vitamins and minerals. MUST was developed by the Malnutrition Advisory Group (MAG), a standing committee of the British Association for Parenteral and Enteral Nutrition (BAPEN). Further information regarding MUST can be obtained from 6 Online MUST training is available at: What is the role of healthcare professionals? It is the health professional s duty of care to consider the patient in a holistic manner. This includes the consideration of every patient s nutritional status. Health professionals are therefore expected to screen patients to identify malnutrition or risk of malnutrition using MUST (pages 5 or 6), implement a care plan which includes giving first line dietary advice and refer onto more specialist healthcare professionals e.g. dietitians, only when appropriate to do so. Care homes (nursing and residential) All patients must be screened for malnutrition on admission and then thereafter as indicated by the MUST flow chart on page 5 2. Community patients (patients in their own homes) (eg community nurse, GP, practice nurse, allied healthcare professional) Screening should be done at initial registration with a patients GP, at the first community nurse contact, when clinical concern and at other opportunities e.g. health checks, flu injections and thereafter as indicated by the MUST flow chart on page 6 2. What is the role of the dietitian? Registered dietitians 7 play a key role in addressing malnutrition; however dietitians are a limited resource. Primarily the dietitian s role is to: 1. establish a whole system approach to addressing malnutrition, for example, providing information and training on MUST, first line dietary advice and the appropriate use of prescribed nutritional supplements to health care professionals 2. use their expertise to see only those patients where a MUST implemented care plan requires dietetic referral, if a patient is receiving no oral nutrition at all, if there are complex dietary needs e.g. coeliac disease, Crohns disease or a modified texture is also required See appendices 8 & 9 for dietetic referral criteria and referral form. If you are uncertain whether to refer a patient, please phone the dietetic department for advice on

6 THE FIVE STEPS OF MUST See Appendix 1 of this document for relevant reference materials. Using the appropriate MUST flowcharts (page 5 or 6) obtain consent then complete the following steps: Step 1: Body Mass Index (BMI kg/m 2 ) score y Establish the patient s BMI score using their height and weight measurements to calculate BMI. y If unable to measure height use a recently documented or self-reported height (if reliable and realistic). If unable to obtain this measure ulna length (Appendix 1) y If unable to obtain a weight a BMI score cannot be derived. See the section below on subjective criteria Step 2: Recent unplanned percentage weight loss score y Establish the patient s weight loss score by exploring any unplanned weight loss experienced over the last 3-6 months. y To calculate percentage weight loss: Percentage weight loss = (previous weight current weight) previous weight x 100 e.g. previous weight = 48kg current weight = 46kg (48 46 = 2) 48 x 100 = 4% Alternatively use the percentage weight loss chart in Appendix 1. Start with the patient s current weight in the non-coloured column on the left. Look horizontally across the chart until the previous weight is found. Look up to the column heading which will give the weight loss score y If recent weight loss cannot be calculated, use self-reported weight loss if reliable and realistic N.B. If significant weight loss within the last 2 weeks consider if the patient could be dehydrated, or whether oedema that was present before has now resolved. Step 3: Acute disease effect score This is used if the patient is currently affected by an acute patho-physiological or psychological condition and there has been (or is likely to be) no nutritional intake for more than five days. This is unlikely to apply in the community apart from in those patients who have reached end of life and action may be inappropriate. Step 4: Overall risk of malnutrition score Establish the patients overall risk of malnutrition by combining the scores for steps 1, 2 and 3. The maximum score that can be achieved is 6. Step 5: Management Guidelines Once the overall risk of malnutrition has been detected, document the score on the MUST record chart (page 7) and implement an appropriate care plan (appendices 2 & 3). Subjective criteria If height, weight or BMI cannot be obtained, other criteria (see Appendices 1 and 10) which relate to them can assist professional judgment of the patient s nutritional risk category. Please note, these criteria should be used collectively, not separately, as alternatives to steps 1 and 2 and are not designed to assign a score. Mid upper arm circumference (MUAC) may be used to estimate BMI category only in order to support your overall impression of the patient s nutritional risk. 4

7 MUST SCREENING TOOL CARE HOMES Patient screened for risk of malnutrition on admission to a care home and then as indicated using MUST score. STEP 1 - BMI Score BMI (kg/m 2 ) Score >20 (>30 obese) = = 1 <18.5 = 2 NB: can be estimated from mid-upper arm circumference (MUAC) STEP 2 Weight Loss Score % Unplanned weight loss in past 3 6 months + % Score + <5 = = 1 >10 = 2 STEP 3 Acute Disease Effect Score If patient is acutely ill AND there has been or is likely to be no nutritional intake for >5 days SCORE 2 Otherwise score 0 STEP 4 Overall risk of Malnutrition (score 0 6) Add scores together to calculate overall risk of malnutrition Score 0 = LOW RISK Score 1 = MEDIUM RISK Score 2 or more = HIGH RISK Assess for underlying cause of malnutrition and refer if appropriate to members of the multidisciplinary team 0 LOW RISK 1 MEDIUM RISK 2 or MORE HIGH RISK y Repeat screening every four weeks* and document on MUST record chart y Re-screen immediately if patient s clinical condition changes y Implement Medium Risk Care Plan (appendix 2) y Repeat screening every four weeks* and document on MUST record chart y Implement High Risk Care Plan y (appendix 2) y Repeat screening every four weeks* and document on MUST record chart 5

8 MUST SCREENING TOOL COMMUNITY NICE 32 (2006) recommends the patient is screened for the risk of malnutrition at initial registration with GP, however practically this is likely to be if there are initial clinical indications to do so (see appendix 10), if subsequent clinical concern, first contact with community nursing, or other opportunistic moments e.g. injections, health checks. STEP 1 - BMI Score BMI (kg/m 2 ) Score >20 (>30 obese) = = 1 <18.5 = 2 NB: can be estimated from mid-upper arm circumference (MUAC) STEP 2 Weight Loss Score % Unplanned weight loss in past 3 6 months + % Score + <5 = = 1 >10 = 2 STEP 3 Acute Disease Effect Score If patient is acutely ill AND there has been or is likely to be no nutritional intake for >5 days SCORE 2 Otherwise score 0 STEP 4 Overall risk of Malnutrition (score 0 6) Add scores together to calculate overall risk of malnutrition Score 0 = LOW RISK Score 1 = MEDIUM RISK Score 2 or more = HIGH RISK Assess for underlying cause of malnutrition and refer if appropriate to members of the multidisciplinary team 0 LOW RISK 1 MEDIUM RISK 2 or MORE HIGH RISK y Repeat screening annually for special groups e.g. those >75 yrs y Re-screen if clinical condition changes or if clinical concern y Implement Medium Risk Care plan (appendix 3) y Repeat screening every four weeks and document on MUST record chart y Implement High Risk Care Plan y (appendix 3) y Repeat screening every four weeks and document on MUST record chart 6

9 Weight on admission or initial contact: Kg MUST RECORD CHART Developed for use with the Malnutrition Universal Screening Tool Weight 3 months before first recorded screening date OR stable weight : Kg Name: Date of Birth: NHS Number: Address or Room Number: Height (m)* or ulna length: Consent: Yes No If measuring MUAC use left arm** Date Current weight (kg) (record MUAC (cm) if unable to weigh) BMI kg/m 2 (wt/ht 2 ) if weight available STEP 1 BMI Score Previous weight 3-6 months ago (kg) (wt before wt loss) Amount of weight lost (kg) (previous wt minus current wt) STEP 2 Weight Loss Score STEP 3 Acute Disease Effect Score (nutrition intake) STEP 4 Overall MUST score (Step 1+2+3) STEP 4 Risk 0=low 1=medium 2+=high STEP 5 Care Plan updated/ continued Print name & Signature Special Instructions: e.g kg kg 5kg High ü A Smith *If height is unavailable, height can be estimated from ulna length (cm) (length between elbow and prominent bone in wrist) ** If unable to measure MUAC on left arm please state reason right arm was used: For more information on MUST see 7

10 IMPLEMENTATION OF THE CARE PLANS (Appendices 2 & 3) 1. Ensure any underlying conditions or problems affecting the patient s risk of malnutrition) are identified and treated (Appendix 4) 2. Ensure adequate hydration 3. Set an appropriate goal with the individual/carer When implementing any nutritional plan you should set a goal, this will help you know when to start withdrawing nutritional therapy (please see flow chart on page 14). The goal you set will need to be specific to each patient and may be one or more of the following: y Target BMI (20-25 Kg/m 2 is the healthy range, however for particular individuals a lower BMI e.g kg/m 2 may be more realistic). Please note that if your patient has a BMI over 25 when you implement a nutrition plan, you would need to aim for a stable BMI rather than aiming to reduce their BMI to the healthy range as they are already in a compromised nutritional state y Target Weight. For some patients it would not be feasible to attain the healthy range BMI above. For these, set a target weight, e.g. the weight before they started losing weight y Prevention of further weight loss y Wound healing. Intervention may be withdrawn safely (see page 14) when the persons wound has healed y Improved mobility y Quality of life. This may be about maintaining current quality of life or increasing quality of life. Please note that for some patients e.g. those with dementia, at the end of life or receiving palliative care it may only be appropriate to focus on quality of life. In these cases provision of food that the patient enjoys should be encouraged providing it is safe to do so in order to slow the decline in weight and function y Maintenance of adequate nutritional intake When setting any goal, ensure it is: Specific Measurable Achievable Realistic Time Appropriate 4. Give first line dietary advice Advice should be provided to encourage the use of energy and protein rich foods in the patient s diet. This is the initial intervention, and should precede the prescription of nutritional supplements in all cases where the patient is able to take foods orally. The first line dietary advice overleaf is supported by the leaflet Food Boosters or Your Guide to making the most of your food (available from which can be given to patients to reinforce the dietary advice provided. The professional providing the patient with first line advice should advise on the aim of therapy which is to improve or maintain nutritional status and avoid malnutrition. This advice must take into account religious and secular beliefs and cultural influences on food intake. Care homes must ensure the food provided complies with this advice 5. Prescribe oral nutritional supplements as guided by the care plan 6. Monitor the intervention as guided by the care plan 8

11 First Line Dietary Advice First line dietary advice should include the following: y Use at least one pint of full fat (whole) milk each day fortified with dried skimmed milk powder (see appendix 5 for recipe) and use in drinks/food throughout the day y Little and often have 2 high calorie snacks (appendix 6) or drinks between meals and a snack/ supper before bed y Enrich food and drinks such as cereals, milk puddings, canned fruit, potatoes, soups and vegetables with cream, butter, margarine, cheese, evaporated milk or sugar* (*unless patient has diabetes) y Drink more milk based drinks made with the fortified milk e.g. milky coffee, malted milk, hot chocolate and milkshakes y Avoid low fat, low sugar* products look for full fat, high sugar* varieties to provide more calories (*unless patient has diabetes) Patients may be reluctant to eat high fat, high sugar foods, so it is important to reinforce the message that preventing weight loss and malnutrition is most important and that first line advice is only meant as a short term measure i.e. general healthy eating messages do not apply (N.B. Patients used to low fat diets may experience nausea if they introduce high fat foods too quickly, so encourage a gradual increase). First Line Advice suitable for a Vegan Diet y First line advice should be followed substituting dairy options for suitable full fat vegan alternatives y Ground almonds can be added to foods y Nut butters e.g. peanut, cashew, hazelnut can be added to cereals, soups, curries, stews (it may help to thin these down with a little water to aid mixing into other foods) y Use vegan cream in hot drinks, poured over fruit or added to desserts y Vegan desserts are available from most supermarkets y Plain chocolate can be given as a snack or used to cook with to add additional energy/protein to foods First Line Advice for patients needing a long term cardio protective diet The above information is designed to be used as a short term measure. For those needing to use food fortification as an ongoing measure and where heart health is a primary concern please use the following advice: y Use at least one pint of semi skimmed milk each day fortified with Dried Skimmed Milk Powder (see Appendix 5 for recipe) and use in drinks/food throughout the day y Drink more milk based drinks made with the fortified milk e.g. milky coffee, malted milk, hot chocolate and milkshakes y Use Monounsaturated Fat sources where possible e.g. olive/vegetable oil, olive oil based spread o Use olive oil as dressings on salads and vegetables o Use olive oil based spreads on bread, in mash etc y Aim to promote fruit and vegetable consumption as these provide a good source of vitamins and minerals o Try almond butter or mashed avocado on toast or crackers as a snack o Add avocado to salads o Snack on dried fruit and nuts such as almonds, brazil nuts etc o Try vegetables such as peppers and carrots with dips as snacks y Aim for 1-2 portions of oily fish per week (e.g. salmon, mackerel, sardines, pilchards, fresh tuna) y Encourage snacks between meals (see appendix 6 for snack ideas) 9

12 Vitamins and Minerals People requiring food fortification still need a balanced diet to ensure they meet their vitamin and mineral requirements. Vitamins and minerals are essential for lots of processes in the body including prevention of anaemia and wound healing. Food fortification is often high in calories and protein at the expense of fruit and vegetables. Try the following tips: y Snack on dried fruit** and nuts y Have fruit** as a dessert but serve with cream, custard or yoghurt y Ensure vegetables present at main meals add salad dressings or olive oil or butter on vegetables y Add fruit** to cereal y Have a small glass of fruit juice** y Try vegetables such as peppers and carrots with dips as snacks ** Be aware that if the patient has diabetes fruit consumption should be spaced out throughout the day to avoid raised blood glucose levels. Patients with diabetes are advised to have only one small glass of fruit juice per day and this should be taken separately to additional fruit. Should you be concerned about the vitamin and mineral status it would be advisable to discuss the requirement for a supplement with the patient s doctor. If, when following the appropriate flow chart, your patient starts prescribable nutritional supplements it is important to remember that these contain added vitamins and minerals. Additional points to consider when providing dietary advice: y Stressful mealtimes patients and carers often find mealtimes stressful due to concern over poor intake. This should be discussed with those involved. Offer reassurance that in the shortterm, small meals with an adequate fluid intake are acceptable because energy requirements may well be reduced due to a reduction in activity levels This situation may often arise in terminally ill patients again reassure that much can be achieved by making mealtimes enjoyable for the patient rather than trying to persuade them to eat larger quantities y The social aspect of mealtimes should be maintained as people often eat better in company. If isolation is a problem, lunch clubs, day care or home helps may be considered y A small glass of alcohol can be a very effective appetite stimulant take approximately half an hour before a meal, maintaining the social aspect of the drink rather than as another medicine. N.B. check alcohol is not a contraindication of medication or medical condition y Cooking smells try to keep the patient away from cooking smells if they find this makes them nauseous and reduces their appetite y Exercise and fresh air often improve appetite and general feeling of well being 10

13 PRESCRIBING NUTRITIONAL SUPPLEMENTS The Advisory Committee on Borderline Substances (ACBS) recommends products on the basis that they may be used as drugs for the management of specified conditions. Prescribers should satisfy themselves that products can be safely prescribed, that patients are adequately monitored and that, where necessary, expert dietetic supervision is available. Procedure for Prescribing 1. The patient must have been screened using MUST and have been identified as requiring nutritional supplements (see MUST care plans, appendices 2 & 3). The patient should be following first line dietary advice as well. 2. Check that the patient s condition falls into one of the ACBS approved categories for prescribing sip feeds: a. Short bowel syndrome b. Bowel fistula c. Intractable malabsorption d. Pre-operative preparation of patients who are malnourished e. Proven inflammatory bowel disease f. Following total gastrectomy g. Dysphagia h. Disease related malnutrition (this could incorporate a range of conditions and is open to interpretation) 3. Issue a prescription, available on FP10, for milk shake style supplements as follows: y 2 sachets/bottles per day to be taken between meals y Issue initial prescription for 1 starter pack * y The patient should try all the flavours and ascertain up to 3 flavours that are liked The most cost effective supplements to prescribe will be: a. i. Powdered milk shake sachets which are currently half the price of ready made supplements. Please note that they need to be made with 200ml full fat milk. This should be the first line supplement if there is someone available to prepare it e.g. care homes, bedded units. This may be difficult for some patients at home to prepare correctly and may have a financial implication for the patient due to the cost of the milk. ii A ready-made low volume, high energy milkshake if the patient is unable to mix up a powdered version with milk. This should provide at least kcal/ml. b. If either of the two supplement types above is not appropriate, or not tolerated, please see Appendix 7 for a list of ranges and companies that make other types of nutritional supplements. * Prescribable starter packs provide a range of styles and flavours of supplements for the patient to try. This approach will increase compliance and avoid wastage resulting from prescriptions for products that the patient will not take. Once decided, the patient should inform the prescriber of their preferred choice of flavour. Packs may offer recipe suggestions and patient preference cards to highlight which flavours are preferred for future prescriptions. Samples of products given by company representatives can only be given to patients by dietitians following the BCHC guidelines regarding samples. All other health professionals are to arrange prescription of a starter pack N.B. Product information contained in these guidelines is correct at the time of print. Please refer to the BNF or MIMS for updates. 11

14 12 4. Once preference is ascertained, a prescription can be issued for one month at a time for two nutritional supplements per day, taken in addition to meals. Some community pharmacists provide a delivery service for patients with transport problems. 5. Patients should be encouraged to take as much of their oral food as possible and not to use supplements as a meal replacement. 6. It should be made clear to the patient/carer that the supplement is only to be consumed by the patient. 7. Patients receiving nutritional supplements should be monitored on a regular basis (see care plans in appendices 2 & 3) to assess the aim of therapy is being met. The GP should be notified of who will be responsible for monitoring the patient. The following should be checked: i. Weight (where possible) or Mid Upper Arm Circumference (if this changes by at least 10% then it is likely that weight and BMI will have changed by approximately 10% or more) ii. Changes in dietary intake following the dietary advice given iii. Compliance with nutritional supplements 8. When the agreed goal of therapy is achieved, nutritional supplements should be gradually reduced using the withdrawing input flowchart (page14). Additional Information y Patients should be advised why they are having nutritional supplements prescribed and that their prescription will be reviewed regularly y As with all drug treatments, compliance with nutritional supplements is vital for a successful outcome. Compliance with nutritional supplements can be improved by: y Explaining the need for, and importance of taking the recommended dose y Taking the nutritional supplement just after a meal or between meals, rather than before y Serving sweet drinks chilled through a straw y Varying the flavours and type of nutritional supplement to help combat flavour fatigue y Ascertaining patient preference and prescribing suitable flavours y From a nutritional point of view there is little to choose between different brands of nutritional supplements. Good compliance is more important than slight differences in the nutritional content of various products y Not all nutritional supplements are suitable for vegetarians and so guidance should be sought from the manufacturers or from the Dietitians. There are very few vegan nutritional supplements and it would be advisable to refer the patient to the Dietitian for specialist advice y As nutritional supplements contain sugar which can contribute to dental caries, patients should be advised to have a sip of water after drinking these to rinse the mouth, and to brush their teeth twice daily with a fluoride containing toothpaste y Patients with diabetes can be given most milk-based supplements but blood glucose levels will need careful monitoring and diabetes medication may need to be altered y Patients with special requirements e.g. Chronic Kidney Disease Stage 4-5, malabsorption etc., may require more specialised products and should be referred to acute dietetic services

15 y Patients with swallowing difficulties who require a modified consistency diet (e.g. puree or thickened fluid) are highly likely to require nutritional supplements to maintain their nutritional requirements y Patients with neurological related swallowing difficulties should be referred to a Speech & Language Therapist who may recommend a modified texture diet and/or a thickening agent to be used or advise on pre-thickened products y Hospital Dietitians requesting that a patient continues on nutritional supplements post-discharge should: o Identify aims of treatment (and target weight where appropriate) to the patient s GP, and should identify and refer to the most appropriate health professional to monitor In the absence of any written correspondence from the hospital dietitians, patients should not be given nutritional supplements post-discharge until they have been reassessed using MUST and the appropriate care plan implemented. This can be carried out by GP, community nurses, care home staff etc. Ongoing care plans/ MUST screening Following an intervention with first line advice and/or prescription supplements, the care plans advise regular screening and review. Should the health professional e.g. community nursing, reach the end of their treatment episode and discharge the patient, they should hand over the ongoing MUST care plan for that patient to another health professional such as the patient s GP. 13

16 FLOW CHART FOR WITHDRAWING ORAL NUTRITIONAL SUPPLEMENTS AND/OR FIRST LINE DIETARY ADVICE This chart should only be used for those patients who are appropriate, as specified in MUST nutritional care plans. Is patient on oral nutritional supplements (ONS)? ONS Sole Source of Nutrition y Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) y Repeat screening every four weeks and document on MUST record chart AFTER FOUR WEEKS Oral Diet and ONS y Decrease the number of ONS by one per day y Continue first line dietary advice y Repeat screening every four weeks and document on MUST record chart Zero ONS y Decrease first line dietary advice actions y Repeat screening every four weeks and document on MUST record chart y Refer to appropriate MUST nutritional care plan if patient is identified to be at risk of malnutrition Weight Loss y Increase the number of ONS by one per day y Continue first line dietary advice y Repeat screening every four weeks and document on MUST record chart Weight Stable or Weight Gain y Repeat screening every four weeks and document on MUST record chart y If continues on ONS refer to oral diet and ONS box y If on zero ONS refer to zero ONS box AFTER FOUR WEEKS y Continue first line dietary advice y Repeat screening every four weeks and document on MUST record chart y Weight Loss Continue ONS and refer to appropriate MUST nutritional care plan y Weight Stable Continue ONS y Weight Increasing Restart withdrawing input flowchart refer to oral diet and ONS box Please Note Some patients will require first line dietary advice and/or oral nutritional supplement prescriptions on an ongoing basis in order to maintain their weight. The need for these should be reviewed every three months. 14

17 PALLIATIVE/END OF LIFE CARE The End of Life Care Strategy published by the Department of Health in July aims to improve access to high quality care for adults approaching the end of life. This should include specialist input of a wider multi-disciplinary team for assessment of individual needs. Key areas of nutritional support within this group include: y Sensitive nutritional screening/assessment taking into account both national and local screening tools y Implementation of dietary changes to optimise nutrition related symptom management. This would include taste acuity, nausea, vomiting, and modified consistency. See Table 8.5, Chapter 8, Royal Marsden Nursing Procedures for further tips (BCHC staff only) y Appropriate use of nutritional supplements and/or appetite stimulants which prove beneficial and are evidence based y Provide practical nutritional advice including written information tailored to individual needs, prognosis and changing circumstances y Ensure that where nutrition support is provided it is warranted and improves quality of life y MDT decisions on role of enteral feeding and withdrawal of feeding within legal boundaries y Emotional support for families coping with anxiety of food provision and hydration Any input should aim to promote effective communication between hospital, hospice, and community settings to ensure consistency of care. You may find the following useful reading: y NHS National Cancer Action Team y The National Council for Palliative Care y Oral Feeding Difficulties and Dilemmas - Royal College of Physicians, January 2010 y Oxford Textbook of Palliative Medicine Oxford University Press 15

18 Recommended Reading RECOMMENDED RESOURCES BAPEN (2010). Malnutrition Matters Meeting quality standards in nutritional care. A toolkit for clinical commissioning groups and providers in England. Available at toolkit-for-commissioners.pdf Care Quality Commission (2010) Essential Standards of Quality and Safety Available at Caroline Walker Trust (2004) Eating well for older people: practical and nutritional guidelines for food in residential and nursing homes and for community meals (2nd edition), Abbots Langley: Caroline Walker Trust. Available at National Institute of Clinical Excellence (NICE) (2010). Chronic obstructive pulmonary disease (updated) Department of Health National Institute of Clinical Excellence (NICE) (2006). Dementia. Supporting people with dementia and their carers in health and social care Department of Health National Institute of Clinical Excellence (NICE) (2006). Nutrition support in adults: oral supplements, enteral and parenteral feeding. Department of Health National Institute of Clinical Excellence (NICE) (2012) Nutrition support quality standard. Department of Health National Institute of Clinical Excellence (NICE) (2005). Pressure ulcers. The management of pressure ulcers in primary and secondary care. Department of Health NHS National Patient Safety Dysphagia Diet Food Texture Descriptors (2011) Available at uk.com/publications/statements/nationaldescriptorstexturemodificationadults.pdf Royal College of Nursing (2007) Enhancing nutritional care- (Nutrition Now Campaign). Available at data/assets/pdf_file/0006/187989/ pdf Royal Marsden Hospital Manual of Clinical Nursing Procedures, Eighth Edition Available to BCHC staff only on the BCHC intranet in the policies section The Department of Health (2007) Dignity in Care - Mealtimes and nutritional care Department of Health The Department of Health and the Nutrition Summit Stakeholders group (2007) Nutrition Action Plan available at DH_ Useful Websites Age UK (Age Concern & Help the Aged) Birmingham Alzheimer s Society Birmingham 16

19 BAPEN (for MUST information) Birmingham City Council, meals on wheels service British Dietetic Association Diabetes UK Macmillan Malnutrition Pathway MENCAP Nutritional guideline for COPD The Stroke Association Parkinson s Disease Society Liverpool Care Pathway Gold Standards Framework CrawlerResourceServer.aspx?resource=EA9E3375-B322-4DA7-84B6-9EC81ACD07B7&mode=link&gu id=9d9423c7b38d49c9b74c02cdc95f1aa2 Water for Healthy Ageing REFERENCES 1. NHS Institute for Innovation & Improvement. QIPP Safe care work stream - Harm free care. www. institute.nhs.uk/safer_care/harm_free_care/harm_free_care_homepage.html 2. NICE (2006). Guidance 32: Nutrition Support in Adults, 3. National Prescribing Centre (2012). Prescribing of adult oral nutritional supplements Elia M. The MUST Report. Malnutrition Advisory Group (MAG), Standing committee of BAPEN. Maidenhead: BAPEN Elia M, Russell C.A (2009) Combating Malnutrition: Recommendations for Action. Report from The Advisory Group on Malnutrition, Led by BAPEN 6. British Association for Parenteral and Enteral Nutrition, Malnutrition Universal Screening Tool 7. The British Dietetic Association 8. Department of Health (2008), End of Life Care Strategy - promoting high quality care for all adults at the end of life. 17

20 REFERRAL PROCESS AND HOW TO CONTACT A DIETITIAN To refer a patient to the Community Dietetic Service, please refer to the referral criteria (Appendix 8) and, if compliant, complete a Nutrition Support Referral Form, ensuring that all information is completed comprehensively, as this will enable a swifter response. The referral must be discussed with the patient and their consent given (or with the carer [best interest] if the patient is unable to consent). Guidance on referring: y Patients should be nutritionally assessed using MUST, and referred to a Dietitian if the relevant care plan indicates this. y Patients can be referred directly to a Dietitian, using a referral form, when a full, detailed nutritional assessment is necessary, or when advice on a specific therapeutic diet is required i.e. diabetes, coeliac disease, renal insufficiency y Patients with swallowing difficulties can be referred to the Dietitian after a swallowing assessment by a Speech and Language Therapist has been completed. y A review by a Dietitian can be requested for patients who have had nutritional supplements prescribed for greater than six months, to ensure that their diet is optimised and that supplements are still appropriate. Please re-refer using a Nutrition Support Referral Form and by completing all patient details. All referrals should be signed by a registered health professional unless the patient is referring themselves, or a carer is on their behalf. Criteria for a home visit A home visit is only available to those who: y are bed-bound y on O2 therapy y in a care home y have GP home visits as unable to attend appointments at the GP surgery All other patients will be given a local clinic appointment. The referral form is available in Appendix 9 or on our website nutrition and should be returned to: Nutrition Support Birmingham Community Nutrition St Patricks Centre Frank Street Highgate Birmingham B12 0YA Tel: Fax:

21 APPENDIX 1 MUST REFERENCE CHARTS Weight (kg) Step 1 BMI score (& BMI) Score 0 (obese) Height (feet and inches) 4'9½ 4'10½ 4'11 5'0 5'0½ 5'1½ 5'2 5'3 5'4 5'4½ 5'5½ 5'6 5'7 5'7½ 5'8½ 5'9½ 5'10 5'11 5'11½ 6'0½ 6'1 6'2 6'3 6'3½ 6'4½ BAPEN Score 0 Height (m) Score 1 Score 2 Note : The black lines denote the exact cut off points (30,20 and 18.5 kg/m 2 ), figures on the chart have been rounded to the nearest whole number. Weight (stones and pounds) 19

22 Step 1 BMI score (& BMI) Height (feet and inches) Weight (kg) 4'9½ 4'10½ 4'11 5'0 5'0½ 5'1½ 5'2 5'3 5'4 5'4½ 5'5½ 5'6 5'7 5'7½ 5'8½ 5'9½ 5'10 5'11 5'11½ 6'0½ 6'1 6'2 6'3 6'3½ 6'4½ Score 0 (obese) Height (m) Score 0 BAPEN BAPEN Note : The black lines denote the exact cut off points (30,20 and 18.5 kg/m 2 ), figures on the chart have been rounded to the nearest whole number. Weight (stones and pounds) 20

23 Score 0 Wt loss < 5% Score 1 Wt loss 5-10% Score 2 Wt loss > 10% Weight 3 to 6 months ago kg Less than (kg) Between (kg) More than (kg) Score 0 Wt loss < 5% Score 1 Wt loss 5-10% Score 2 Wt loss > 10% Score 0 Wt loss < 5% Score 1 Wt loss 5-10% Score 2 Wt loss > 10% Weight 3 to 6 months ago Weight 3 to 6 months ago kg Less than (kg) Between (kg) More than (kg) kg Less than (kg) Between (kg) More than (kg) Score 0 Wt loss < 5% Score 1 Wt loss 5-10% Score 2 Wt loss > 10% Weight 3 to 6 months ago kg Less than (kg) Between (kg) More than (kg) Current weight Current weight BAPEN Step 2 Weight loss score 21

24 Alternative measurements and considerations Step 1: BMI (body mass index) If height cannot be measured Use recently documented or self-reported height (if reliable and realistic). If the subject does not know or is unable to report their height, use one of the alternative measurements to estimate height (ulna, knee height or demispan). Step 2: Recent unplanned weight loss If recent weight loss cannot be calculated, use self-reported weight loss (if reliable and realistic). Subjective criteria If height, weight or BMI cannot be obtained, the following criteria which relate to them can assist your professional judgement of the subject s nutritional risk category. Please note, these criteria should be used collectively not separately as alternatives to steps 1 and 2 of MUST and are not designed to assign a score. Mid upper arm circumference (MUAC) may be used to estimate BMI category in order to support your overall impression of the subject s nutritional risk. 1. BMI Clinical impression thin, acceptable weight, overweight. Obvious wasting (very thin) and obesity (very overweight) can also be noted. 2. Unplanned weight loss Clothes and/or jewellery have become loose fitting (weight loss). History of decreased food intake, reduced appetite or swallowing problems over 3-6 months and underlying disease or psycho-social/physical disabilities likely to cause weight loss. 3. Acute disease effect Acutely ill and no nutritional intake or likelihood of no intake for more than 5 days. Further details on taking alternative measurements, special circumstances and subjective criteria can be found in The MUST Explanatory Booklet. A copy can be downloaded at or purchased from the BAPEN office. The full evidence-base for MUST is contained in The MUST Report and is also available for purchase from the BAPEN office. BAPEN Office, Secure Hold Business Centre, Studley Road, Redditch, Worcs, B98 7LG. Tel: Fax: bapen@ sovereignconference.co.uk BAPEN is registered charity number BAPEN 2003 ISBN Price 2.00 All rights reserved. This document may be photocopied for dissemination and training purposes as long as the source is credited and recognised. Copy may be reproduced for the purposes of publicity and promotion. Written permission must be sought from BAPEN if reproduction or adaptation is required. If used for commercial gain a licence fee may be required. BAPEN. First published May 2004 by MAG the Malnutrition Advisory Group, a Standing Committee of BAPEN. Reviewed and reprinted with minor changes March 2008, September 2010 and August MUST is supported by the British Dietetic Association, the Royal College of Nursing and the Registered Nursing Home Association. BAPEN 22

25 Alternative measurements: instructions and tables If height cannot be obtained, use length of forearm (ulna) to calculate height using tables below. (See The MUST Explanatory Booklet for details of other alternative measurements (knee height and demispan) that can also be used to estimate height). Estimating height from ulna length Measure between the point of the elbow (olecranon process) and the midpoint of the prominent bone of the wrist (styloid process) (left side if possible). Height (m) Height (m) Height (m) Height (m) men (<65 years) men ( 65 years) Ulna length (cm) Women (<65 years) Women ( 65 years) men (<65 years) men ( 65 years) Ulna length (cm) Women (<65 years) Women ( 65 years) Estimating BMI category from mid upper arm circumference (MUAC) The subject s left arm should be bent at the elbow at a 90 degree angle, with the upper arm held parallel to the side of the body. Measure the distance between the bony protrusion on the shoulder (acromion) and the point of the elbow (olecranon process). Mark the mid-point. Ask the subject to let arm hang loose and measure around the upper arm at the mid-point, making sure that the tape measure is snug but not tight. If MUAC is <23.5 cm, BMI is likely to be <20 kg/m 2. If MUAC is >32.0 cm, BMI is likely to be >30 kg/m 2. The use of MUAC provides a general indication of BMI and is not designed to generate an actual score for use with MUST. For further information on use of MUAC please refer to The MUST Explanatory Booklet. BAPEN 23

26 Additional notes for using the MUST reference charts 1. The BMI values on the BMI charts provided with the MUST have been rounded to the nearest whole number. The yellow shaded area represents BMI values of kg/m 2. Therefore, values of 20 which lie above this shaded area represent values greater than 20 and less than 20.5 kg/m 2. Values of 18 which lie below this area represent values less than 18.5 and above 17.5 kg/m Care should be taken when interpreting the patient s BMI or percentage weight loss if any of the following are present: Fluid disturbances: i) BMI. More significant if underweight with oedema; subtract ~ 2 kg for barely detectable oedema (severe oedema is >10 kg; see The MUST Report); can use MUAC when there is ascites or oedema in legs or trunk but not arms; re-measure weight after correcting dehydration or over hydration; inspect the subject to classify as thin, acceptable weight, or overweight/obese. ii) Weight change. When there are large and fluctuating fluid shifts, a history of changes in appetite and presence of conditions likely to lead to weight change, are factors that can be used as part of an overall subjective evaluation of malnutrition risk (low or medium/high risk categories). Pregnancy: i) Pre-pregnancy BMI. Measured in early pregnancy; self reported or documented weight and height (or estimated using measurements in early pregnancy); MUAC at any time during pregnancy. ii) Weight change. Weight gains <1 kg (<0.5 kg in the obese) or >3 kg per month during the 2 nd and 3 rd trimester generally require further evaluation. See The MUST Report for further details. Lactation: i) BMI Measured BMI ii) Weight change As for oedema (above). Critical illness: Acute disease effect (and no dietary intake for >5 days). This generally applies to most patients in intensive care or high dependency units. Plaster casts: BMI Synthetic and plaster of paris casts for upper limb weigh <1 kg; lower leg and back kg depending on material and site. See The MUST Report for further details. Amputations: BMI Adjustments of body weight can be made from knowledge of missing limb segments: upper limb 4.9% (upper arm 2.7%; forearm 1.6%; hand 0.6%); lower limb 15.6% (thigh 9.7%; lower leg 4.5%; foot 1.4%). Calculations to obtain pre-amputation weights: Amputation Calculation Below knee Current weight (kg) x Full leg Current weight (kg) x 1.18 Forearm Current weight (kg) x Full arm Current weight (kg) x For those patients who are identified as being overweight or obese and are acutely ill, the need to address weight loss should be postponed until that individual is in a more stable clinical position. Contact the dietetic service if unsure. 24

27 Name: APPENDIX 2 CARE PLAN FOR CARE HOMES MUST Score 1 à Medium Risk of Malnutrition MUST Score 1 y Implement first line dietary advice (see page 9) y Review hydration status (see page 29) y Set a weight/dietary goal (see page 8) y Repeat screening every four weeks and document on MUST record chart D.O.B./NHS Number: Details of Weight/Dietary Goal: Date: Print name: Signature: If No Improvement or Further Decline y Continue current plan y Trial with 1-2 nutritional supplements per day (see page 11) y Repeat screening every four weeks and document on MUST record chart AFTER FOUR WEEKS Improved Nutritional Status i.e. eating more, weight increasing/ stable y Continue current plan y Repeat screening every four weeks and document on MUST record chart y Once patient reaches target set refer to withdrawing input flowchart Date: Print name: Signature: AFTER FOUR WEEKS Date: Print name: Signature: If No Improvement or Further Decline Not Compliant with Supplements y Check timings of supplements y Try different flavours, variety, type of supplement (see page 33) y Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) y Continue with first line dietary advice y Repeat screening every four weeks and document on MUST record chart Date: Print name: Signature: Compliant with Supplements y Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) y Continue current plan y Repeat screening every four weeks and document on MUST record chart Date: Signature: Print name: Improved Nutritional Status i.e. eating more, weight increasing/stable y Continue current plan y Repeat screening every four weeks and document on MUST record chart y Once patient reaches target goal refer to withdrawing input flowchart Date: Signature: Print name: 25

28 CARE PLAN FOR CARE HOMES MUST Score 2 or more à High Risk of Malnutrition Name: D.O.B./NHS Number: MUST Score 2 or MORE y Implement first line dietary advice (see page 9) y Review hydration status (see page 29) y Trial with 1-2 nutritional supplements per day (see page 11) y Set a weight/dietary goal (see page 8) y Repeat screening every four weeks and document on MUST record chart Details of Weight/Dietary Goal Date: Print name: Signature: AFTER FOUR WEEKS If No Improvement or Further Decline Not Compliant with Supplements y Check timings of supplements y Try different flavours, variety, type of supplement (see page 33) y Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) y Continue with first line dietary advice y Repeat screening every four weeks and document on MUST record chart Compliant with Supplements y Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) y Continue current plan y Repeat screening every four weeks and document on MUST record chart Improved Nutritional Status i.e. eating more, weight increasing/stable y Continue current plan y Repeat screening every four weeks and document on MUST record chart y Once patient reaches target goal refer to withdrawing input flowchart Date: Print name: Signature: Date: Signature: Print name: Date: Signature: Print name: 26

29 APPENDIX 3 CARE PLAN FOR COMMUNITY PATIENTS MUST Score 1 à Medium Risk of Malnutrition Name: D.O.B./NHS Number: MUST Score 1 y Implement first line dietary advice (see page 9) y Review hydration status (see page 29) y Repeat screening every four weeks and document on MUST record chart Date: Print name: Signature: AFTER FOUR WEEKS If No Improvement or Further Decline y Continue with first line dietary advice y Prescribe 1-2 nutritional supplements per day (see page 11) y Repeat screening every four weeks and document on MUST record chart Improved Nutritional Status i.e. eating more/weight increasing/stable y Continue current plan y Repeat screening every four weeks and document on MUST record chart y Refer to withdrawing input flowchart Date: Signature: Date: Signature: Print name: Print name: AFTER FOUR WEEKS If No Improvement or Further Decline y Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) y Continue current plan y Repeat screening every four weeks and document on MUST record chart Improved Nutritional Status i.e. eating more/weight increasing/stable y Continue current plan y Repeat screening every four weeks and document on MUST record chart y Refer to withdrawing input flowchart Date: Signature: Date: Signature: Print name: Print name: 27

30 CARE PLAN FOR COMMUNITY PATIENTS MUST Score 2 or MORE à High Risk of Malnutrition Name: D.O.B./NHS Number: MUST Score 2 or MORE y Implement first line dietary advice (see page 9) y Review hydration status (see page 29) y Ask GP to prescribe 1-2 nutritional supplements per day (see page 11) y Review progress with care plan weekly y Repeat screening every four weeks and document on MUST record chart Date: Print name: Signature: AFTER FOUR WEEKS If Clinically Concerned y Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) y Continue current plan y Repeat screening every four weeks and document on MUST record chart Date: Print name: Signature: If No Improvement or Further Decline y Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) y Continue current plan y Repeat screening every four weeks and document on MUST record chart Improved Nutritional Status i.e. eating more, weight increasing/stable y Continue current plan y Repeat screening every four weeks and document on MUST record chart y Refer to withdrawing input flowchart Date: Print name: Signature: Date: Print name: Signature: 28

31 APPENDIX 4 IDENTIFYING UNDERLYING CAUSES OF NUTRITIONAL DEFICIENCIES, AND ACTION PLANS Underlying Cause Action Loss of Appetite: Medical y Dehydration y Fever y Depression y Recovery from infection y Constipation y Diarrhoea y Nausea y Taste changes y Posture y End of Life Environment y Embarrassment at meal times y Smell y Other people y Food provision y Ensure daily fluid intake is ml/kg y Discuss treatment with patients GP/case manager i.e. laxative, anti-emetic, etc. A medication review could check if any medication is contributing to nausea, taste change, constipation etc y Follow MUST flow charts (page 5 or 6) y Consider referral to Occupational Therapist, Physiotherapist or Speech and Language Therapist for advice regarding seating and posture and swallowing difficulties y Consider the dining habits of other people, providing adequate time, finger foods or adaptive cutlery to promote independence y Ensure no offensive smells at meal times y Ensure other people are not providing a distraction e.g. other residents. Try limiting visiting times at meal times. Conversely, they may eat better with other people around them. y Ensure appropriate foods offered are appealing and correctly portion sized for the person Difficulty Eating: y Problems handling food e.g. arthritis, reduced dexterity y Problems with chewing e.g. poor dentures y Unable to take solid food y Difficulty with swallowing y Discuss with Occupational Therapist y Consider finger foods that do not require utensils to eat y Refer to Dentist y Investigate underlying cause y Refer to Speech and Language Therapist y BCHC staff, see Chapter 8, Royal Marsden Nursing Procedures for more information about dysphagia) 29

32 y Patient no longer able/inclined to feed themselves y Problems with memory e.g. Alzheimer s y Advise carers y Provide assistance with all food/drinks (BCHC staff, see Procedure Guideline 8.9, Royal Marsden Nursing Procedures) y Promote regular scheduled meals y Food diary y Carers to prompt patient to eat Inability to retain or absorb food: y Nausea or vomiting for >4 days y Diarrhoea: loose stools >3 days y Malabsorption y Investigate cause and treat (take sample and send for investigation) y Encourage adequate oral fluid intake y Refer, via GP to a gastrointestinal unit for advice on management Disease state with implications for nutrition support: y Inflammatory bowel disease, infection, major surgery, malignancy, pressure sores, leg ulcers y Liver or renal disease y Follow appropriate MUST flow chart (page 5 or 6) y Refer to relevant specialist unit if necessary y Chronic Kidney Disease (stage 4 and 5) needs to be seen by a renal specialist Dietitian (secondary care) Social Situation: y Limited support for shopping, cooking or feeding e.g. 3-4 days per week or evenings only y No support for shopping, cooking or eating y Refer to Social Services for Meals Direct/ Home Help/Day-Care/Lunch Clubs or other services y Refer to Social Services for care package Using a multi disciplinary team approach will help improve your patients compliance and nutritional status. 30

33 APPENDIX 5 BOOSTING THE CALORIES RECIPE ADAPTING Adapting the recipe Energy Kcals (calories) Food item 1 portion Before After Milk 1 pint Add 4 heaped tablespoons dried skimmed milk (dsm) powder to 1 pint whole milk extra 106% Custard Large ladle (125mls) Add 1 heaped tablespoon dsm powder & 2 tablespoons double cream to custard made with whole milk extra 143% Soup Large ladle (125mls) Add 1 heaped tablespoon dsm powder & 2 tablespoons double cream to soup extra 250% Porridge Large ladle (125mls) Add 1 heaped tablespoon dsm powder & 2 tablespoons double cream to porridge made with whole milk extra 118% Mashed potatoes 1 scoop Add an extra 1 heaped teaspoon of margarine/butter and 1 tablespoon of cream to mashed potatoes extra 170% Vegetables 2 tablespoons Add 1 heaped teaspoon of margarine/butter to vegetables. Allow to melt Ice cream 1 small scoop Pour 2 tablespoons of double cream over the ice cream extra 460% extra 100% Sponge pudding 2 tablespoons Place an extra 2 teaspoons of jam or syrup to the sponge when serving. Then serve with high calorie custard or ice cream extra 58% Breakfast cereal Small serving (25g) Use fortified milk with 2 tablespoons double cream and 2 teaspoon sugar extra 115% Milk pudding Large ladle (125mls) Add 1 heaped tablespoon dsm powder & 2 tablespoons double cream to the milk pudding made with whole milk serve with 2 teaspoons jam extra 150% 31

34 APPENDIX 6 Increasing the calories The foods listed below vary from approximately calories each and can be added to any appropriate meal, or eaten as a snack in between meals, to help you increase your calories. 100 calorie Savoury spreads and toppings y Peanut butter (16g)* y 1 level tbsp mayonnaise (15g) y Average serving of salad cream (30g) y 2 tbsp hummus (50g)* y 1 heaped tbsp pesto (20g) Sweet spreads and toppings y 1 heaped tbsp sugar (25g) y 2 heaped tsp honey (35g) y 2 heaped tsp golden syrup (35g) y 2 heaped tsp lemon curd (35g) Dairy y 2 tbsp skimmed milk powder (30g)* y 150ml full fat milk* y 1 scoop icecream (60g) y 75ml evaporated milk* y 30ml condensed milk y 1 small pot full fat yogurt* y 30ml coconut cream y 1 medium slice cheddar cheese* Fruit and Nuts y Small handful of peanuts (30g)* y 5 Brazil nuts (15g)* y Small handful cashew nuts (20g)* y 1 heaped tbsp sultanas (35g) y 2 dried apricots (50g) y 2-3 dates (40g) y 6 prunes (60g) 200 calorie y Ham sandwich (1 slice bread, butter and ham)* y Fairy cake y Malt loaf (1 slice with butter) y ½ fruit scone/hot cross bun with butter and jam y Medium size sausage roll* y Meringue nest with whipped cream 250 calorie y ½ Teacake/crumpet with butter and jam y 1 slice sponge/fruit cake y 1 medium pork pie* y Jam/paste sandwich (1 slice bread, butter and jam/paste) y Individual Bakewell tart/fruit pie y 1 ring/mini doughnut y Individual trifle 300 calorie y Small slice of flapjack y ½ fruit scone with jam, butter and cream y 2 slices malt loaf with butter y Cheese and biscuits (2 crackers with butter and cheese)* y Danish pastry y Chocolate bar (e.g. Twix, Mars) Snacks y 2 digestive biscuits y 5 jelly babies y 2 fingers of KitKat y ½ a Crunchie y 1 Fudge bar y Bag of crisps *Also a good source of protein (tbsp. = tablespoon, tsp = teaspoon) 32