Guidance for Oral Nutritional Support in patients with disease related malnutrition

Transcription

1 Guidance for Oral Nutritional Support in patients with disease related malnutrition NICE (CG3, 6) define oral nutrition support (ONS) as the modification of food and fluid by: fortifying food with protein, carbohydrate and/or fat plus minerals and vitamins; the provision of snacks and/or oral nutritional supplements as extra nutrition to regular meals, changing meal patterns or the provision of dietary advice to patients on how to increase overall nutrition intake by the above. Comparisons were made between ONS and standard care in malnourished patients, however studies were small and NICE concluded Since oral nutritional supplements presumably produce clinical benefits through increased nutrient intake, a similar increase in nutrient intake achieved by dietary means, should lead to similar clinical benefits. First Line Therapy for disease related malnutrition is FORTIFIED NORMAL FOOD Consider the patient s current food intake and eating patterns; could this be altered to include more calories and protein as well as encouraging more food to be eaten. Steps to take before considering prescribing an oral nutritional supplement (ACBS).. Assess and record Nutritional Status using MUST guidelines.. Try fortified normal food (by adding milk, butter, cream or cheese) 3 meals plus 3 snacks as first line therapy for 4 weeks. 3. Check compliance and record weight after 4 weeks on fortified foods. 4. Ensure patients receive appropriate dietary advice (give written information) from suitably trained member of the primary health team 5. Nutritional supplements may suppress appetite and decrease food intake, constipation may become a problem and patients may become bored with taste and texture of supplements prescribed. Prescribing Guidance for Nutritional Supplements in the community. Nutritional supplements MUST not be on repeat prescriptions.. Establish aim of treatment with patient and plan for stopping treatment.. Do not exceed 5-6kcals daily (i.e. or portions of nutritional supplements). 3. Encourage patients to take supplements between meals, they are not intended to be a meal replacement but to provide additional nutrition e.g. mid-morning, mid-afternoon and at supper time 4. Initial prescription should be for a week period to establish product preference. 5. Prescribe a further 4 weeks prescription of an acceptable supplement. 6. Patients should be reassessed and monitored at this time. 7. Monitoring: Regular weight and BMI monitoring and a compliance check is practical and sufficient in most cases. Record at point of each prescription. 8. Consider referral to dietitian if weight loss continues after 6-8 weeks or if there is other change in medical needs. Prescribing Supplementary Feeds for patients residing in care homes The essential standard 4 Meeting nutritional needs specifies that service users are protected from the risks of inadequate nutrition and dehydration, by means of the provision of a choice of suitable and nutritious food and hydration, in sufficient quantities to meet service users needs and support, where necessary, for the purposes of enabling service users to eat and drink sufficient amounts for their needs. Therefore only in exceptional circumstances after consultation with a dietitian should a nutritional supplement be prescribed. Weights must be provided at monthly intervals to assess benefit for prescribed supplements.

2 Flowchart for Providing Nutritional Support to Community Patients Patients at high risk (MUST SCORE or more) after 4 weeks on a high calorie /protein diet and weight loss continues. Record patient s BMI/weight and risk of under nutrition (MUST score). Establish and record aim of treatment. Issue an acute prescription for 4 units of a supplementary feed - Take one twice daily (midmorning/bedtime). Supplements of choice are Complan Shake or see box below for alternatives. Prescribe a variety of flavours to establish preference. (e.g. Complan Shake - chocolate, strawberry, banana, vanilla or milk.) Powdered Supplements e.g. Complan Shake needs to be made up with fresh whole milk to ensure calorific intake. If patient is likely to have difficulties preparing product or dislikes/intolerant to milk prescribe alternative listed below. If patient is compliant with Complan Shake issue a monthly, acute prescription of sachets/day of the patient s preferred flavours. If Complan Shake is unacceptable; prescribe from the starter packs listed below. If acceptable issue a monthly, acute prescription for cartons/bottles per day of patient s preferred product and flavour(s). After one month review the patient- Record weight and MUST score Improvement i.e. either: Risk of under nutrition reduced from high to moderate BMI /Weight increased to target or appetite has returned to normal No Improvement i.e. either: BMI/Weight has declined BMI/Weight stable/increased but appetite remains poor Continue with a high calorie/high protein diet until patient is at low risk of under nutrition Stop all dietary supplements Check the patient s compliance Compliant Taking dietary supplements/day Non compliant Taking < dietary supplements/day BMI/Weight stable/increased but appetite remains poor Issue monthly prescription of preferred product Issue as an acute BMI/Weight has decreased Refer the patient to the dietetic services. Prescribe alternative supplement (,) - Issue a week trial prescription If non compliant trial another product from list If compliant issue month acute If problems identified in finding a suitable supplement, refer the patient to the dietetic services. Monthly review for 6 months If patient prescribed dietary supplement for >6 months refer to dietetic service for a review. Difficulties with preparation: Forti Sip Range (Nutricia) starter pack: packs contain mixture of milk based, juice based and yoghurt type sip feeds. Dislike milk: Prescribe a juice based supplement Diabetic: Prescribe High Fibre. Alternative Supplements - Milk based Clinutren, Resource Shake, Fresubin Energy, Ensure Plus, Fortisip bottle. TAKE twice daily - Powdered Enshake, Scandishake Calshake TAKE once daily - Yoghurt Based Ensure Plus yoghurt, Fortisip Yogurt Style, TAKE twice daily - Juice Based Fortijuce, Enlive Plus, Resource Fruit, TAKE twice daily - High Fibre Fortisip multifibre, Fresubin Energy Fibre, Enrich Plus, TAKE twice daily. - Fortisip Savoury Multi Fibre, TAKE twice daily

3 Malnutrition Assessment This tool is designed only to assess those at risk of malnutrition. Patients who require advice about diet for any other reason e.g. Diabetes, hyperlipidaemia, renal disease etc. may be referred if necessary to the Dietitian. Surname: Forename: ID Number: Tel No: D.O.B Assessment Tool (MUST guidelines) Date Total Score Total Score Total Score or more Step-BMI/Weight BMI > (acceptable weight/ overweight BMI 8.5- (thin) BMI <8.5 (very thin/ obvious wasting) Step-Unplanned Weight Loss (last 3-6 mths) <5% weight loss (weight gain/ no significant weight loss) 5-% weight loss >% weight loss. Step 3-Acute Disease Effect No problem with eating or drinking Little nutritional intake > 5days Acutely ill and there has been or is likely to be no nutritional intake for >5 days Total Score=(step+step+step3) Treat underlying conditions Requires assistance with eating and drinking No/ Yes Requires special diet No/ Yes.. Low risk Medium risk High risk Give written advice on Healthy Eating. Repeat Assessment Care homes - monthly Community - annually For special groups e.g. those >75yrs every to 3 months. Take First Line Actions Record food and fluid intake for 5 to 7 days. Care home- kitchen to provide 3 high calorie meals plus 3 nutritious snacks or milky drinks per day. Community - Advise on nourishing diet (give leaflet/diet sheet) Repeat Assessment : Care homes - at least monthly Community - at least every or 3 months If improved or adequate intake then repeat assessment as in previous column. First Line Actions as in previous column. Care Homes Consider referral to dietetics, if first line actions not effective in improving nutritional status. Community, consider prescription of oral supplement COMPLAN SHAKE only after compliance check and plan for stopping treatment is established. Complan shake first choice Monitor and review care plan Care Home - monthly Community - monthly If no improvement then consider referral to Dietitian and recommence food chart. Adapted from the BAPEN MUST tool and NICE guideline 3.

4 Monitoring Sheet For Patients on High Protein Diet and/or Supplementary Feeds. All patients prescribed supplementary feeds require MONTHLY monitoring. Aim of treatment should be agreed and a plan for stopping the supplement. It is not intended that supplements be used in general for poor appetite. FOOD FORTIFICATION remains FIRST LINE Surname: Forename: DOB Food Fortification Advice Given-Insert Date Fortified Diet Commenced-insert Date as BMI= Aim of Treatment: e.g. achieve BMI of -----kg/m */ maintain weight * / regain % or---- KG */ restoration of good appetite *. * delete/use as appropriate Supplementary feeds Commenced (Insert Date) as BMI = Nutritional indicator Date MUST Screening Score Weight BMI No Of Meals/day No Of Snacks/day Appetite,,or same Needs help with eating(y/n) Dysphagia (Y/N) Consistency of Food (N,P,L)* No of Supplements/day Poor dentition/dentures(y/n) Able to do own shopping (Y/N/NA) Mobility,,or same Specific Function-specify * *N normal P puréed L liquid Speech and Language Therapist can advise on appropriate eating. * Specific function e.g. COPD, Wound Healing, mental Condition

5 Food and Drink Intake Chart Please record everything you eat and drink for a 5 to 7 day period. This will help us to monitor your progress. Please record what is actually eaten, also what is served, and state quantities e.g. one Slice of toast and butter, tablespoon mashed potato, sausages, mug milky coffee. Surname: Forename: ID Number: Tel No: D.O.B Food Fortification Advice Given-Insert Date Fortified Diet Commenced-insert Date as BMI= Aim of Treatment: e.g. achieve BMI of -----kg/m */ maintain weight * / regain % or---- KG */ restoration of good appetite *. * delete/use as appropriate Breakfast Day date Day date Day 3 date Day4 date Day5 Mid Morning Snack Lunch Mid Afternoon Snack Evening Meal Supper