Rehabilitation & Assessment Directorate Nutrition and Dietetic Service

Transcription

1 Rehabilitation & Assessment Directorate Nutrition and Dietetic Service A guide to the Use of the MUST ( Malnutrition Universal Screening Tool) for Care Home Residents Nutrition and Dietetic Service Old Johnstone Clinic 1 Ludovic Square Johnstone updated April 2012

2 Contents 1. Introduction 2. MUST Guidance Notes 3. MUST Tool (including Body Weight Calculation in Amputees guidance) 4. Nutritional Support Pathway Local policy 5. Nutritional Support : First line dietary advice 6. Sample Food Fortification Menus 7. Weekly Food intake Chart 8. Ideas for Finger Food Meals 9. Use of Oral Nutritional Supplements (ONS) 10. First line advice for other dietary conditions: Constipation Diabetes Weight Management Iron deficiency anaemia 11. Dietetic Referral Guidance and Referral Form Updated April2012

3 Introduction A Nutrition and Dietetic Service Review Group within Renfrewshire was set up in 2008 with a remit to : Ensure a clinically effective service is available to meet the needs of residents in care homes Promote the recommendations of NHS Greater Glasgow and Clyde, Quality improvement Scotland, Food, Fluid and Nutritional Standards and the Care Commission Standards As a result it was agreed: MUST ( Malnutrition Universal Screening Tool) would be the preferred screening tool for residents in all Care Homes within the area. Each care home unit would be provided with resources to ensure the use of the appropriate care pathway for residents requiring nutritional support Care homes would Identify Nutrition Link staff to be trained in use of MUST, local care pathway and implementation of 1 st line nutritional support for residents. These staff would be responsible for informing and training other staff their care home. Details of the available training programme would be issued regularly to care homes and also from the address listed in the front of this folder. This pack contains the MUST papers and supporting resources for use within the Care Home Please note that additional copies of MUST and other resources can be obtained from Renfrewshire CHP s website at Updated April 2012

4 MUST Guidance Notes The Care Commission (now known as the Care Inspectorate) recognises that nutrition in care homes is fundamental to good care and residents should have access to varied and nutritious foods, which meet the individuals requirements. The National Care standards state that care homes should provide nutritious meals, which reflect food preferences and special dietary needs. They also state that Nutritional Screening should be part of every resident s care planning. Purpose of these guidance notes These notes are to enable the consistent use and interpretation of MUST (Malnutrition Universal Screening Tool) What is MUST The Malnutrition Universal Screening Tool ( MUST ) has been designed to help identify adults who are underweight and at risk of malnutrition, as well as those who are obese. It has not been designed to detect deficiencies in or excessive intakes of vitamins and minerals. When should MUST be used? MUST is designed to be used for all new residents and thereafter for review of residents as indicated by the pathway. Who should fill out the MUST tool? The tool should be filled out by a member of staff who has full access to the resident s : Current Height & Weight BMI ( Body Mass index) Previous weight (preferably over several weeks or months) Previous and current dietary intake either by observation, discussion with resident / relatives / other staff or by use of weekly food intake charts. Any medical condition affecting dietary intake What preparation is required prior to using the MUST? Obtain copy of MUST assessment tool either specific tool within residents care plan or obtain from website Have all appropriate patient information as above. Using MUST Complete assessment tool:- Step 1 Obtain score for BMI Step 2 Obtain score for weight loss Step 3 Obtain score for Acute Disease Effect ( Note that this refers to an acute episode of illness where there is NO nutritional intake for several days, it does not apply to patients with small intake of food or drink or those with chronic disease affecting food intake) What next? Follow the Local Nutritional Support Pathway to decide the appropriate action that should be taken. Must Guidelines page 1

5 When should I request advice from Dietitian? The Local Nutritional Support Pathway will guide you to when you should refer a resident to the dietitian. This will normally be after you have tried 1 st line advice for at least 4 weeks without improvement. However if you have concerns regarding a resident you can telephone the dietetic department for further advice on What about residents who are not underweight but have other dietary concerns? MUST should be used for all residents to assess the need for dietary advice Advice is available for conditions other than weight loss / poor appetite including (SEE SECTION 10); Diabetes Weight management Constipation Iron deficiency anaemia What if I follow the Nutritional support pathway and it advises me to refer resident to Dietitian? You will be required to arrange for the Nutrition and Dietetic Service Referral Form to be completed and sent to the Old Johnstone Clinic. This form can be completed by the Nurse in Charge, manager or the residents General Practitioner It is important that all parts of the form are completed otherwise the referral will be returned to the referrer and this will delay treatment for the resident. Continue to provide 1 st line Dietary advice until you are contacted by the dietitian. What will the Dietitian do when referral received? The referral will be checked to ensure that all the necessary information has been included and the resident will be placed on a waiting list for assessment. Within a short period of time the care home will be contacted by telephone by someone from the Dietetic service. At this time you will be asked to provide a summary of the 1 st line Dietary advice that has already been carried out and information about resident s weight over the previous few weeks. If you do not have access to this information ask the Dietitian to call back at a time when the information will be available. After discussing the resident with staff the Dietitian will agree a plan of action with you and if appropriate arranged to visit the care home to discuss further. Will the Dietitian visit the care home until patient reaches an optimum weight? No, the dietitian will provide whatever support is appropriate for your resident. This may involve visits to the care home or it may be support to staff via telephone. Once the dietitian is satisfied the resident is progressing, everything that can be done is being done or that contact is no longer appropriate, this will be discussed with care home staff and a future action plan / discharge from dietetic service agreed. Who do I contact if I am unsure whether referral is required or what has been previously agreed with dietitian? If you need advice contact Nutrition & Dietetic Service Old Johnstone Clinic 1 Ludovic Square JOHNSTONE PA5 8EE Must Guidelines page 2

6 A full copy of the MUST screening tool can be downloaded from the following website:-

7 Body weight calculations in amputees: For amputations, increase weight by the percentage below for contribution of individual body parts to obtain the weight to use to determine Body Mass Index Body Part Upper Limb Upper arm 2.7 Forearm 1.6 Hand Lower Limb Thigh 9.7 Lower Leg 4.5 Foot 1.4 % of body weight 4.9 Table reproduced from Manual of Dietetic Practice Fourth edition published 2007 by Blackwell Publishing Ltd

8 Nutritional Support care pathway - Local Policy (Care Homes) Patient identified as requiring nutritional support via MUST screening Non Nutritional factors present Swallowing difficulties MUST score 0 Low Risk MUST score 1 Medium risk MUST score 2 or more High Risk Respite residents -social situation limited support, Problems with food preparation or shopping Refer for Home Support or other Social Services Problems with Chewing Refer to Dentist Refer to Speech & Language Therapist Other medical condition requiring dietary change e.g Diabetes, overweight refer to appropriate information leaflet Little clinical concern - Repeat screening: Hospital weekly Care Homes monthly Community annually for special groups e.g over 75 s Re asses at least monthly Observe and document dietary intake for 3 days Intake adequate or Improved no improvement or intake found to be inadequate Clinical concern : Treat unless detrimental or no benefit is expected e.g imminent death Follow First Line Dietary Advice and record weekly food chart. Check weight weekly if possible Intake good or improved Weight stable or increased No improvement. Weight / intake continues to deteriorate Reinforce First Line Dietary Advice Refer to Dietitian

9 NUTRITIONAL SUPPORT: First Line Dietary Advice If screening identifies patient or resident requires nutritional support the following measures should be taken. 1) Weigh weekly to establish extent of weight loss & record food intake chart 2) Start FOOD FORTIFICATION and encourage little and often (see table below for ideas) 3) If a modified consistency has been advised, ensure the CORRECT CONSISTENCY for food and fluids continues to be provided when fortifying food and drinks (use thickeners if prescribed) 4) RE ASSESS at least monthly and if no improvement in appetite, food intake or weight-refer to Dietitian. WHAT? WHY? WHEN? FORTIFIED MILK 1 pint of full cream milk with 4 tablespoons of dried milk powder added PORRIDGE & CEREALS Add honey*, sugar*, dried fruit, double cream or yogurt MAIN or COOKED MEALS Add butter, margarine, cream or cheese to potatoes. Add grated cheese over vegetables, in sauces or scrambled egg. Add mayonnaise, salad cream and dressings generously. Add butter, margarine or a creamy sauce to vegetables. SMALL MEALS and SNACKS Try small sandwiches with cold meat, cheese or tuna, toast with cheese or cheese spread, yogurts, mousses, scone, cake, cereal bar, milky drink, toast & banana, cheese & biscuits SOUPS & PUDDINGS Soups - add fortified milk, double cream, or cheese. Puddings - make with or add fortified milk, add evaporated milk, double cream, honey*, or jam*. Offer small carton of custard or rice pudding as a snack. Add stewed or tinned fruit DRINKS Almost nutritionally equivalent to 2 pints : Significantly increases energy & protein content without more volume. Adds extra calories Good alternative if resident dislikes cooked food & refusing main meals & sandwiches. Adds extra calories Adds taste to meals Helps encourage vegetable intake to increase fibre, vitamins & minerals to help immune system and wound healing. It is often difficult to get enough in at meal times. Easier to eat than main / cooked meals. Reduces need for Prescribed Nutritional Supplements Increase energy & protein content. Even average portions of soup & pudding will have a significant nutritional value if fortified. More appealing than a large meal. Fruit and vegetables help ensure adequate fibre, vitamin & mineral intake to help immune system & wound healing. USE PINT OVER THE DAY IN HOT DRINKS, CEREALS, PORRIDGE, MILK SHAKES & PUDDINGS CAN OFFER AT ANYTIME, NOT JUST AT BREAKFAST e.g. supper or mid-morning. IF QUANTITY EATEN AT MEAL TIMES IS SMALL PORTION. AIM FOR 1-2 VEGETABLES DAILY IN MEALS OR SOUPS IF MAIN MEALS REFUSED REGULARLY OR NOT FINISHED. AIM FOR 3 SMALL MEALS & 3 SNACKS PER DAY. IF MAIN MEAL REFUSED CAN OFFER SOUP & PUDDING TWICE A DAY IF NOTHING ELSE TAKEN. MAKE SOUPS WITH PLENTY VEGETABLES AND PULSES AIM FOR 2-3 PORTIONS OF FRUIT A DAY e.g MASHED BANANA, TINNED FRUIT, SMOOTHIES BETWEEN OR AFTER MEALS MILKY - add extra fortified milk in tea & coffee, make Ovaltine* / Horlicks* or hot chocolate* with fortified milk. FRUIT JUICE or ORDINARY DILUTING JUICE* ( try to use one with added Vitamin C and aim for 1-2 glasses a day) BUILD-UP / COMPLAN (buy in) Cups of tea & coffee alone have little nutritional value. Reduces need for Prescribed Nutritional Supplements. N.B. It is still important to ensure adequate fluids are taken over the day. AVOID DRINKS JUST BEFORE OR WITH MEALS AS CAN REDUCE APPETITE. FRUIT JUICE AT BREAKFAST OR MID MORNING- TRY SMOOTHIES ADD SUGAR* OR HONEY* TO DRINKS WHERE POSSIBLE TO INCREASE ENERGY CONTENT. Not advised routinely if patient Diabetic - contact a Dietitian if concerned about a Diabetic resident. Nutrition and Dietetic Service, Old Johnstone Clinic, 1 Ludovic Square, Johnstone PA5 8EE tel

10 Sample Food Fortification Menus Below you will find three sample menus:- Menu 1 Not fortified Menu 2 Partly fortified: adds additional 24.7g protein and 988 kcalories Menu 3 Fully fortified: adds additional 43g protein and 1731 kcalories These menus show the benefit from fortifying a diet to increase both protein and calorie content. This can be compared with providing one bottle of a nutritional supplement which only adds 13.8g Protein and 320 calories. Menu 1 Not fortified Meal Time Standard Food Protein Kcals (g) Breakfast Porridge made with water Mid Morning Lunch Mid afternoon Evening meal Homemade soup White roll Small banana Minced meat and gravy 1 boiled potato carrots Tinned peaches in juice 0 40 Evening snack 2 x Plain Biscuits Milk in tea and ½ pint of semi-skimmed milk coffee Total Fortified diet menu page 1

11 Menu 2 Partly fortified Meal Standard Food Protein(g) Kcals Breakfast Porridge made with full cream milk and teaspoons sugar Mid Morning Lunch Mid afternoon Evening meal Homemade soup with added double cream White roll and butter ½ banana and 1 scoop ice cream Minced meat and gravy 1 scoop of mashed potato with butter and milk Carrots with butter Milk pudding with Tinned fruit in syrup and cream Evening snack 1 slice toast with butter and jam Additional milk 1 pint of full cream milk for teas / coffees over the day and one milky drink Total Menu 3 Fully fortified Meal Time Fully Fortified Foods Protein(g) Kcals Breakfast Porridge made with fortified full cream milk and 2 teaspoons sugar Mid Morning 2 x crackers thickly spread with butter Lunch Homemade soup with added double cream White roll and butter ½ banana and 1 scoop ice cream Orange Juice Mid Afternoon Evening Meal Malt loaf and thickly spread butter Glass of full cream fortified milk Minced meat and gravy 1 scoop of mashed potato with butter and cream Carrots with extra butter Milk pudding with Tinned fruit in syrup and cream Evening snack 1 slice toast with butter and jam Additional milk 1/3 pint of fortified full cream milk for teas over the day / coffees etc Total Fortified diet menu page 2

12 Weekly Food Intake Chart Name Week Beginning Weight kg Breakfast sample Monday Tuesday Wednesday Food offered Amount Eaten porridge with fortified milk & cream Fresh Orange Juice 1 bowl 1/2 Food Offered Amount Eaten Food Offered Amount Eaten Food Offered Amount Eaten Mid am Lunch mid pm Evening Meal early evening supper glass fortified milk plain biscuit Homemade soup with full cream milk. milk pudding with puree fruit and double cream Scone with butter cup of tea with milk & 2 tsp sugar macaroni cheese glass fortified milk 1 build up or complan drink tea with milk & sugar 1 slice white bread toasted with butter jam all 2 ½ bowl ½ bowl 1 TBSP 1/4 all none none all 1/2 1/2 * Please also record any nutritional supplements offered and amount taken e.g Ensure plus, Calogen

13 Breakfast Thursday Friday Saturday Sunday Food Offered Amount Eaten Food Offered Amount Eaten Food Offered Amount Eaten Food Offered Amount Eaten Mid am Lunch mid pm Evening Meal early evening supper Any other relevant Information Nutrition & Dietetic Service, Old Johnstone Clinic, 1 Ludovic Square, Johnstone PA5 8EE tel updated April 2012

14 IDEAS FOR FINGER FOOD MEALS Finger Foods are useful for clients on the move or those who have difficulty with cutlery but still wish to be able to eat independently. Tips Try to supervise meals & snacks where possible & give prompting and assistance if required. Some finger foods may be too dry or hard for client therefore provide sauces & gravy for savoury foods / cream, evaporated milk or milk puddings for sweet foods to be used as a dip therefore making food more moist. Offer milk & milky drinks between meals at suppertime. Try leaving snacks near client & in room so they can help themselves. Aim for 3 small meals and 3 snacks each day BREAKFAST BETWEEN MEAL SNACKS LUNCH EVENING MEAL Chopped fruit Toast fingers with butter & cheese spread, smooth peanut butter or meat paste French Toast & slices of tomato Toast fingers with small sausages Cereal bar. Bowl of dry breakfast cereal Served with separate drink of milk or fruit juice Pancake with butter & jam 2 Digestives with butter & jam Scone with butter & jam Toast fingers & smooth peanut butter Crackers & cheese Crisps Bread sticks & dip Popcorn Toast fingers with butter & jam Malt loaf & butter Banana sandwich Toasted teacake with butter & jam Sandwiches made with egg mayo, cheese & coleslaw. Chopped apple & grapes. or Mini quiche & chopped salad & vegetables. New potatoes. Ginger cake. or Cheese & ham toastie Crisps. Fruit chunks. or Tortilla wrap with various fillings. Iced sponge cake. Fish fingers & potato croquettes. Broccoli. or Chicken drumsticks Bread & butter. Carrot sticks (boiled or raw). or Cold meat. Potato wedges. Salad vegetables. or Snack pizza. Cold pasta salad or salad vegetables. Ice-cream cone/jelly cubes/ Individual fruit pie/meringue /Tinned fruit Remember to include a glass of fresh fruit juice and 1 pint of milk / milky drinks daily and ensure other fluids are offered regularly throughout the day. Aim for 6-8 mugs or glasses of e.g. tea, coffee, squash, water. Nutrition & Dietetic service, Old Johnstone Clinic, 1 Ludovoc Square, Johnstone. PA5 8EE tel updated April 2012

15 USE OF ORAL NUTRITIONAL SUPPLEMENTS (ONS) A drug is not prescribed unless its function is known, what effect it should have on the body, possible side-effects and what the outcome is likely to be. Newly commenced medications are reviewed and it is often expected that they will be stopped once a satisfactory outcome is achieved or if patient complains of problems -The same should apply to Oral Nutritional Supplements (ONS) and they should always be used as part of a treatment plan. Appropriate Prescribing of Oral nutritional Supplements (ONS) In some instances a resident may be unable to achieve their nutritional requirements from fortified diet even with encouragement from staff. When this happens it may be recommended to prescribe an oral nutritional supplement For some care home residents it can be appropriate to prescribe a small supply of supplements when they experience poor food intake as a result of a period of illness when they are unable to achieve their nutritional requirements from fortified diet. Nutritional supplements may be indicated in residents receiving active treatment for palliative care where supplements could improve clinical / nutritional outcome and quality of life. The nutritional screening tool and care pathway should still be used for this group of patients. Where treatment has been withdrawn and a patient s condition is deteriorating the Dietitian can be contacted to discuss whether further advice or whether ONS are required. What is inappropriate prescribing? Prescribing supplements not suitable to a resident's condition. Repeated prescribing for long period of time without review. Prescribing before dietary advice is tried (unless exceptional circumstances) Prescribing supplements without clear instructions on how to use them and for how long. Prescribing without regular review to monitor dietary and supplement compliance. It may be inappropriate to use or suggest ONS in residents who are terminal, especially in the last few days of life. Normal food that the resident enjoys should always be encouraged as much as possible. The aim should be to minimise stress at meal times. It has been shown that that ONS have little or no value in weight stable residents with a BMI or those who are overweight BMI >25. What are the risks of inappropriate prescribing? ONS can in many situations simply replace food and have no real benefit to the resident. They could result in drug-nutrient interactions, which could reduce the effectiveness of the drug and the ONS Some ONS can cause side-effects such as diarrhoea, nausea and vomiting. Monitoring the use of Oral Nutritional Supplements (ONS) Ideally a Dietitian should monitor patients taking ONS but as this is not always possible the following should be carried out to ensure proper use. The residents should be weighed weekly, food intake charts recorded daily and compliance with ONS prescribed should be noted Staff should review resident s progress at least monthly as per the Nutritional support Pathway Local policy. Ensure resident is taking the amount of ONS advised. Discontinuing Oral Nutritional Supplements (ONS) Long term use of ONS is not recommended. Once the aim of the treatment is reached, ONS should be gradually reduced while the patient's weight is monitored :- Review the reason for the resident taking ONS and if appropriate reduce the dose over a period of time Re check weight and food intake, then reduce dose further until they can be stopped. Remove prescription from repeat if this was arranged. Review progress in 3 months. Updated April 2012

16 First Line Advice for Other Dietary conditions If MUST screening identifies no concern with residents appetite or weight but patient has another condition requiring dietary modification the attached leaflets may be useful for First line Advice before referring to the Dietitian. Leaflets Included Diabetes Weight management Constipation Iron deficiency anaemia Updated April 2012

17 Here are some meal ideas. Breakfast Branflakes, Weetabix or reduced sugar muesli with banana and semi-skimmed milk. Granary/High fibre or wholemeal toast and reduced sugar marmalade. Healthy choice yoghurt with chopped fresh fruit. Porridge with semi-skimmed milk and a small glass of orange juice. Snack meal Lentil soup, bread roll and a banana. Diabetes page 1 First line advice for diabetes If the patient or resident has been recently diagnosed with diabetes a referral to the dietitian should be arranged. The advice in this leaflet can be followed until an initial assessment by the dietitian is carried out If the patient or resident has had diabetes for some time use the information in this leaflet to ensure the correct diet is provided, referral to the dietitian is only required if the patient or resident has difficulty following this advice or if their doctor has identified that control is poor. Baked beans on toast. Healthy choice yoghurt and an apple. Cold meat and tomato sandwiches. Fresh fruit. Main Meal Lean mince with potatoes, carrots and cabbage. Chicken and vegetable casserole, potatoes. Pasta with tomato and vegetable sauce. Breaded haddock (oven baked) with oven chips, peas and tomato. Compiled by Nutrition and Dietetic Service, Renfrewshire CHP August 2008 The picture above shows the correct balance of foods for a healthy diet. The diet for people with diabetes is a normal healthy diet low in fat, sugar and salt, with plenty starchy foods, fruit and vegetables.

18 Diabetes page 2 Here are some tips to help control diabetes. Use less sugar Eat regular meals including breakfast, a snack meal and a main meal each day Include starchy foods such as bread, cereals, potatoes, rice or pasta at every meal. High fibre varieties are best. Encourage a variety of fruit, vegetables and pulses (such as beans, peas and lentils) every day Aim for 5-a-day (older residents with small appetites may only manage 3-4 portions). Provide fewer fried and fatty foods such as full cream milk, cheese, chips, pies and pastries. Offer semi-skimmed milk and reduced fat cheese Reduce use of butter and margarines use low fat spreads instead or spread butter or margarine thinly. Choose lower fat desserts e.g yoghurt, It is not necessary to avoid sugar completely, however, foods and drinks that contain a lot of sugar can make the blood glucose rise too quickly so :- Use diet or sugar free drinks and avoid adding sugar to drinks and food. Change to low sugar and sugar free foods such as healthy choice yoghurts, sugar free jelly and fruit tinned in juice (not syrup). There is no need to buy special diabetic foods as they can be expensive, have a laxative effect and will not help weight control. Use only a little salt in cooking and discourage the adding of salt at the table Alcohol should only be taken in moderation Losing weight can help to control sugar levels. Even a small weight loss will make a difference. Increasing activity levels can also help with control of sugar levels and weight encourage where possible e.g walking, chair aerobics, carpet bowls.

19 How Much Weight Could I Lose? A resident may wish to know how reducing snacks and fatty or sugary foods will affect their weight and it is important to explain that small changes can really make a difference. This list shows how much weight can be lost in a year by cutting down on high fat / high sugar foods. Cut this out each day: In 1 year you could lose: 1 tablespoon of oil 23lbs (10kg) 1oz butter or margarine 23lbs (10kg) 2teaspoons sugar in 6 daily cuppas 25lbs (11kg) 1 iced cake 21lbs (9.5kg) 2 thinly buttered cream crackers 16.5lbs (7.4kg) 1 buttered scone 27lbs (13kg) 1 chocolate biscuit 13.5lbs (6kg) 1 packet crisps 14.5lbs (6.5kg) 1 chocolate bar 30 lbs (13.6kg) 1 packet boiled sweets (50g) 17 lbs (8kg) 1 glass cola 12.5lbs (5.5kg) 1 large measure spirits 11.5lbs (5kg) 1 glass wine 11lbs (5kg) 1 pint beer/lager 16lbs (7kg) 3 plain biscuits 20lbs (9kg) Average portion chips 31lbs (14kg) 1 slice cheddar cheese (if eaten in addition to meals) 17lbs (8kg) 1/3pint(200ml)full fat milk (if taken in addition to that required for tea/cereal) 13lb (6kg) First line advice for weight Management If the patient or resident has been gaining excess weight and it has been identified that their BMI ( Body Mass index) is above 25, the advice in this leaflet can be followed initially. For many residents no other intervention will be required but if First Line Advice fails to stop weight gain after 2 3 months, a referral to the Nutrition and Dietetic service may be appropriate. Produced by the Nutrition and Dietetic Department, Renfrewshire CHP, August 2008 Weight management page 1 The picture above shows the correct balance of foods for a healthy diet. The diet for people who are trying to lose weight is a normal healthy diet low in fat, sugar and salt, with plenty of starchy foods, fruit and vegetables.

20 Weight management page 2 Some tips to help residents lose weight Eat regular meals including breakfast, a snack meal and a main meal each day. Fill up with plenty of starchy foods such as bread, potatoes, rice and pasta Encourage a variety of fruit and vegetables every day aim for 5-a-day (older residents with smaller appetites may only manage 3-4 portions) Here are some meal ideas. Breakfast Branflakes, Weetabix or reduced sugar muesli with banana and semi-skimmed milk. Granary/High fibre or wholemeal toast and reduced sugar marmalade. Healthy choice yoghurt with chopped fresh fruit. Porridge with semi-skimmed milk and a small glass of orange juice. Reduce use of butter and margarines, use low fat spreads instead or spread butter and margarine thinly. Choose lower fat desserts e.g yoghurt Provide fewer fried and fatty foods such as full cream milk, cheese, chips, pies and pastries. Encourage resident to cut out sugar added to tea, coffee or cereals. Offer fresh fruit or bread instead of cakes and biscuits. Advise resident only to eat sweets and chocolate occasionally. Aim for weight maintenance or weight loss of 1lb per week depending on residents initial BMI, mobility and age. Keeping food intake charts can help to show where changes could be made. Snack meal Lentil soup, bread roll and a banana. Baked beans on toast. Healthy choice yoghurt and an apple. Cold meat and tomato sandwiches. Fresh fruit. Main Meal Lean mince with potatoes, carrots and cabbage. Chicken and vegetable casserole, potatoes. Pasta with tomato and vegetable sauce. Breaded haddock (oven baked) with oven chips, peas and tomato. What if I Resident is get hungry between meals? Offer a tomato or banana sandwich, soda scone, potato scone or fruit instead of biscuits or crisps.

21 Low calorie chocolate drinks or soups are also useful.

22 MENU IDEAS BREAKFAST: Branflakes with milk and banana Wholemeal Toast Glass of fruit juice LUNCH: 2 slices wholemeal bread Tuna and cucumber or tomato Fruit or muesli bar MID-PM: Fruit or wholemeal scone EVENING MEAL: Minced beef or roast chicken Carrots and broccoli Jacket potatoes SUPPER: Oatcakes with tomato OR Wholemeal toast with reduced sugar jam CHECKLIST FOR CHANGE Do not make too many changes at once but gradually increase the fibre intake to avoid flatulence and bloating Try making one change at a time After about one month check if you are doing the following: Encouraging breakfast, especially high fibre cereals Offering more bread, especially wholemeal (aim for 3-6 slices daily) Providing potatoes, rice or pasta at mealtimes Offering 5 portions of fruit and vegetables daily Ensuring 6-8 mugs of fluid daily First Line Advice for Constipation Being constipated is enough to make anyone feel miserable it is uncomfortable, causes bloated and results in a resident spending long sessions in the toilet. Although laxatives and other medication may be prescribed it is essential that the resident s diet contains sufficient dietary fibre and fluids. This leaflet gives advice on the types of foods that will increase the fibre in a resident s diet. The attached Fibre Counter will help you check how much fibre a resident is taking check this initially and then gradually increase as required. Never increase fibre content of the diet suddenly, changes should be made over a period of a few weeks to prevent bloating and discomfort. WHAT IS FIBRE? Fibre is the part of cereals, fruit and vegetables which is not digested and passes through the body without being absorbed. It absorbs liquid which provides a soft bulk that is easy to pass when we go to the toilet. WHY EAT FIBRE? Fibre in the diet helps to keep the bowels moving regularly and so prevents constipation. It also adds bulk to the diet, making us feel full for longer and so helps to control appetite. Too little fibre also seems to be related to other bowel disorders including piles and diverticulitis. In addition to the high fibre foods it is important to take extra fluid to help the fibre to swell. Try to encourage the resident to take at least 6-8 mugs of fluid daily. Compiled by Nutrition and dietetic Service, Renfrewshire CHP August 2008 Constipation page1

23 WHICH FOODS ARE HIGH IN FIBRE? There are different types of fibre which have different effects on the body. It is therefore important to encourage residents to choose foods every day from each of the groups listed below. STARCHY FOODS Try to include generous portions from this group at every meal. Bread, especially wholemeal and high fibre white. Try to take 3-6 slices daily. Fruit loaf and wholemeal / fruit scones Wholegrain breakfast cereals e.g. weetabix, branflakes, porridge Rice and pasta, especially the brown varieties Wholegrain biscuits e.g. digestive, oatcakes, wholegrain crackers Potatoes keep the skins on where possible a baked potato with skin has twice as much fibre as one without PULSES, LEGUMES AND SEEDS These include peas, beans, lentils and nuts. All kinds are suitable fresh, frozen, tinned or dried Soups lentil, pea and ham Baked beans on toast Chilli with kidney beans Peanut butter on bread Add beans and peas to mince or stews Sprinkle seeds e.g. sunflower onto cereals or stews FRUIT & VEGETABLES Try to include at least 5 portions daily Include one or two helpings of vegetables with meals e.g. carrot, cabbage, turnip, salad Add salad to sandwiches Add carrot, onion, mushrooms or peppers to mince or stews Include plenty of vegetables in soup e.g. lentil, broth Put chopped fresh fruit into yoghurt, milk puddings or cereals Make fruit salad and provide a handy snack chop a variety of fruit, put in a bowl and keep moist by adding a sugar free fizzy drink DON T FORGET THE FLUIDS! All residents should be offered at least 6 8 mugs of fluid per day ( The total minimum recommendation of fluid is 1500mls daily) Recommended fluids include water, flavoured water, fruit juices, squash, milk, tea and coffee. Residents identified at risk of dehydration should be on a fluid balance chart to ensure sufficient fluids are being taken Constipation page2

24 FIBRE COUNTER CHART. FOOD QUANTITY FIBRE (g) STARCHY FOODS 2 med. 4.5 Bread wholemeal Slices/rolls Bread white 2 large slices/rolls 1.5 Bread whole-white 2 med. slices/rolls 3 Porridge Medium bowl 1.5 Cereal wholegrain e.g. Small bowl 4.0 Branflakes, muesli Potato with skin 2 medium size 4.0 Potato without skin 2 medium size 2.0 Pasta wholemeal Average portion 7.0 Pasta white Average portion 2.0 Rice brown or savoury Average portion 1.5 FRUIT/VEGETABLES Apple, orange, banana etc. 1 medium 2.0 Dried fruit e.g. raisins 2 tablespoons 1.0 Tinned fruit 1 small tin 1.0 Green Vegetable / cauliflower 2 tablespoons 2.0 Root vegetable e.g. carrot 2 tablespoons 1.5 Peas, sweetcorn 2 tablespoons 3.0 Tomatoes 2 medium or ½ tin 1.5 salad Small portion 2.0 BISCUITS / CAKES Digestives 3 average 1.0 Oatcakes 2 round 1.0 Fruit cake / loaf 1 slice 1.0 Scone wholemeal 1 medium 2.5 Scone plain 1 medium 1.0 SOUPS, BEANS, PULSES, LEGUMES & SEEDS Lentil, split pea, broth 1 bowl 3.0 Minestrone, vegetable 1 bowl 2.0 Baked or kidney beans 2 tablespoons 8.0 Chick peas 2 tablespoons 3.0 Butter beans 2 tablespoons 5.5 Peanuts/peanut butter 1 tablespoon 1.5 Seeds e.g. sunflower 2 tablespoons 1.5 Constipation page3 Fibre Counter Chart and Menu Form Use this table to record the food eaten in one day. Estimate quantity of each food and calculate the fibre content using the list on the chart. N.B. Some foods do not contain any fibre e.g. chicken, meat, fish, milk, cornflakes, white rice Meal Food eaten Quantity Fibre content Breakfast Mid-morning Lunch Mid-afternoon Evening meal Bed-time Other You should aim to increase gradually to approximately 18g fibre per day for elderly residents. If constipation persists you can increase gradually to 20-25g per day. Remember to include 6-8 mugs of fluid daily

25 INCREASING THE IRON IN YOUR DIET Iron is needed to make healthy blood cells and we need to eat some every day. It has been should that the elderly are at more risk of Iron deficiency anaemia. There are 2 types of iron :- Haem iron is the more easily absorbed type and is found in red meat,oily fish and dark meat from poultry. Non-Haem iron is not so easily absorbed and is found in cereals, pulses and some vegetables. Absorption of iron from these foods can be increased by taking a source of vitamin C along with them e.g. fruit juice, tomatoes, citrus fruit, or green leafy vegetables. What Foods will increase Iron Intake? Red Meat e.g. Mince, stew, chops, lamb, liver, liver pate, kidney, black pudding, corned beef. Poultry - Dark meat of chicken and turkey. Fish -tinned sardines, pilchards, fish paste,clams & oysters. Breakfast cereals with added iron e.g. Branflakes, Cornflakes,Cheerios. Dried fruits e.g.prunes, raisins, apricots, dates. Bread especially wholemeal and brown. Egg yolk Beans and pulses including baked beans, kidney beans, butter beans, lentils,soya beans,tofu and chickpeas Spinach, kale and spring greens Chocolate (milk & plain) Treacle and liquorice. Increasing Iron page1

26 MEAL IDEAS Breakfast Branflakes, milk & glass of grapefruit juice or Prunes & yoghurt, wholemeal toast & orange juice or Cornflakes,milk and glass of tomato juice Snack Meal Lentil & tomato soup with wholemeal bread or Baked beans on wholemeal toast with glass of fruit juice or Corned beef & tomato sandwiches or Sardines on toast & fresh fruit salad Main meal Mince,potatoes and peas or Liver casserole,potatoes and broccoli or Spaghetti Bolognaise with salad or Chicken drumsticks, sweetcorn and potatoes or Potato & spinach curry with boiled rice and salad Useful tips Include a source of haem iron at meal times whenever possible i.e red meat, tinned fish,dark poultry meat. Provide foods containing vitamin C along with iron containing foods e.g. fruit,fruit juice and vegetables. Offer breakfast cereals fortified with iron every day. Advise resident to avoid taking tea or coffee with iron containing foods as these drinks can reduce the absorption of iron. If the doctor has advised the resident to take iron tablets offer a glass of fruit juice at the same time to help absorption. Compiled by Nutrition and Dietetic Service Old Johnstone Clinic 1 Ludovic Square, Johnstone. PA5 8EE tel Updated April 2012 Increasing Iron page2

27 Rehabilitation & Assessment Directorate South Clyde Nutrition & Dietetic Service Referral Guidance Background The Health Professions Council (HPC) allows dietitians to accept referrals from any health or social care professional. However, prior to assessing and advising a patient the dietitian must have all the relevant information to ensure compliance with the HPC Standards of conduct, performance and ethics. 1. Method of referral / Where to send referral Preferred method of referral: The Nutrition and Dietetic Service accepts electronic referrals through the SCI Gateway. This type of referral provides the dietitian with the information requested above and is the preferred method of referral from General Practitioners. Other methods of referral Referrals to the Nutrition & Dietetic Service can also be made in writing to: Nutrition and Dietetic Service Old Johnstone Clinic 1 Ludovic Square, Johnstone PA5 8EE (Standard referral forms can be obtained from this address or by telephoning ) Urgent referrals for Housebound patients Please note that if the referral is for a housebound patient and it is considered that a lack of dietetic intervention will lead to condition deteriorating to potentially life threatening status or hospital admission then an urgent referral should be made via ASeRT (the Adult Service Request Team) on (see apponitment category below for guidance on urgent outpatients) Obesity Management referrals Please note we are unable to accept out patient referrals for adults who require advice to manage their obesity. These patients should be referred to the Glasgow and Clyde Weight Management Service (GCWMS). If your patient would be unable to attend outpatient / clinic appointments even with the use of the NHS patient transport service (which is available for patients who are referred to the GCWMS), please contact us to discuss their case before referring. 2. Acceptance of Referrals All referrals received by the Nutrition & Dietetic Service are screened by a dietitian who will check to ensure that the referral is appropriate for the Nutrition & Dietetic Service and that it contains all required patient information as indicated overleaf. Once the referral has been checked and accepted, the dietitian will confirm the priority of the patient and place on our waiting list for the first available appointment. For written referrals, referrers can opt to receive notifiation that their referral has been received and accepted by the service on the referral form. Referrers using the SCI gateway can ascertain if the referral has been received by the service using the icon within the gateway. If you wish, you can also phone the service to confirm that the referral has been received and accepted referral guidance page 2

28 Appointment category - You can indicate a preferred appointment category which the service will use to help inform a final decision on the patient s priority. To help you do this, it may be helpful for you to know that urgent is defined as lack of dietetic intervention that will lead to a condition deteriorating to potentially life threatening status and routine is defined as lack of dietetic intervention that will lead to compromised nutritional status 3. Detail to include on referral The following information is mandatory for all referrals. If any of this information is not available the referral should state this and include reason why it is not available, or contact the service on to discuss this, otherwise referral will be returned to the referrer requesting the missing information. Date Name, address and post code of patient 10 digit Community Health Index (CHI) (this can be obtained from GP records) Type of appointment required i.e. out-patient or domicilary (if patient is house-bound only) Any known risk factors for lone working, e.g. alcohol/drug use, violence Details of referring person Details of GP Diagnosis and reason for referral Previous medical history Current medication Additional information is also required for some patients: Blood results e.g HbA1c or blood glucose for diabetes, U s & E s for liver problems, EGFR for renal problems or iron level for anaemia. Height, weight & BMI, weight history - required for overweight or underweight children, adults with unexplained weight loss or other conditions where weight is significant e.g diabetes, lipid alteration Relevant social information e.g lives alone, receives community meals, wheelchair user, literacy or speech problems, hearing impairment MUST score (Malnutrition Universal Screening Tool) and details of any first line advice already carried out should be provided for patients referred for nutritional support and / or unplanned weight loss 4. Rejected Referrals Referrals will only be rejected if a dietitian identifies that essential information is missing. In order to ensure effective and efficient dietetic assesssment and treatment for your patient we will return the referral along with a request for the information required. It is important to highlight that the patient will not be placed on our waiting list until completed referral is returned. If you are unsure if your patient would benefit from dietary intervention or you would like to discuss where your referral should be sent please contact us on to discuss with the dietitian. April 2012 referral guidance page 2

29 Rehabilitation & Assessment Directorate Patient Referral to Nutrition and Dietetic Service All Fields are mandatory, however if any of the requested information is not available please either indicate Date: Patient Name: Address: reason or contact us on to discuss before referring Appointment Category: routine or urgent see referral guidance for definition of urgent patient Appointment Type: out-patient in patient *housebound patient day patient *If patient is housebound is there any lone working risk when visiting at home? Yes No Not Known If YES give details Postcode: 10 digit CHI Number: This can be obtained from GP or Hospital notes and must be included in referral Referrer Name: Address: Patient Telephone Number: GP Name: Address: Postcode: Telephone Number: Postcode: Telephone Number: Designation/ Job title: Referrer s Signature: Do you require notification that the service have received and accepted this referral? Yes No Diagnosis and Reason for Referral Height: Weight: BMI: MUST Score: (for those at risk of malnutrition) Details of any 1 st line advice or intervention already carried out:- Previous medical and weight history: Current medication: Relevant blood results: See referral guidance Any additional relevant information e.g social factors, psychiatric or mental health issues: Please send to The Nutrition and Dietetic Service, Old Johnstone Clinic, 1 Ludovic Square, Johnstone. PA5 8EE April 2012