Nutrition versus Malnutrition SSOTP Dietitians https://www.staffordshireandstokeontrent.nhs.uk/services/malnutrition-make-everymouthful-matter.htm
Aim of the Session Improve knowledge - causes and consequences of malnutrition Increase awareness of Stafford Nutrition Support Guidelines referral to dietitian Empower carers to ensure patients receiving adequate nutrition/ hydration Ensure care staff are able to calculate MUST score and based on MUST score set a treatment goal
Whose responsibility is good nutrition?
Malnutrition Facts - BAPEN 3 Million, 19.2 billion, 30-35% 3 million adults are malnourished in UK and many more at risk. In 2011-12 malnutrition cost 19.2 billion total in health and social care It occurs in all healthcare settings 30% of adults admitted to hospital and 35% in care settings are malnourished
Causes of Malnutrition Different meal environment Lack of assistance at meal-times Difficulty with feeding Dislikes meals Depression/ Anxiety/ Apathy Medical condition Malabsorption Pain Energy needs Medication Loss of appetite/ altered taste
Effects of Malnutrition Longer wound healing Development of pressure ulcers General Tiredness and Fatigue Muscle weakness Falls Immobility Feeling colddifficulty getting warm Low Mood Confusion- reduced memory Reduced immune system more illnesses and infections
Fluids and Dehydration Aim: 30-35ml of fluid per kg of body weight per day 45kg (7 stone) approx 1.5litres daily 64kg (10 stone) approx 2.2 litres daily Dehydration is higher in older people: Reliance on drinks being provided Forgetting to ask Forgetting to drink Worry about getting to toilet on time/ waking at night
Effects of Dehydration Urinary tract infection (UTI) Reduced urine output colour Reduced skin elasticity Unpleasant taste in mouth Drowsiness Confusion Lower Blood Pressure Falls
6 Steps to appropriate Nutritional Care Staffordshire Nutrition Support Guidelines 1. Identification of Nutritional Risk (Calculate MUST) 2. Assessment of Cause of malnutrition 3. Clear treatment goals should be documented on the patient record 4. Make every offering food first advice 5. Review Prescribe oral nutritional supplements if no change 6. Treatment goal met? Review and discontinue oral nutritional supplements
6 Steps to appropriate Nutritional Care Staffordshire Nutrition Support Guidelines Step 1-Identification of Nutritional Risk (Calculate MUST)
Malnutrition Universal Screening Tool - MUST Looks at body weight, height and percentage weight loss Rapid or regular weight loss is a cause for concern BMI under 18.5 should prompt investigation BUT may be normal for this person
MUST Steps BMI Amount weight loss Current medical condition Add your MUST score Plan of care
Step 1 BMI score Need weight in kg or Stones Need Height in meters or feet Example: Weight 55kg, Height 1.62m What is BMI?
Step 2 Weigh Loss Score All you need - weight! And amount lost! (in KG) over 3-6 months Was 58 kg 3 months ago now 55 kg - loss of 3kg in 3 months see table for score
Step 3 Acute Disease Effect Score Patients who are acutely ill AND have had or are likely to have no nutritional intake for more than 5 days Most likely to apply to patients in hospital (particularly acute hospitals) Add 2 to score
Add Scores together BMI Score Weight Loss Score Acute Disease Effect Score =MUST Score Follow Staffordshire Nutrition Support Guidelines to develop care plan and to give advice
Staffordshire Nutrition Support Guidelines If there is a MUST Score of 2 move to STEP 2 commence pathway MUST score of 3 or more refer to Dietetic Service (and also commence pathway) Also refer to dietitian if: On ONS as sole source of nutrition Require artificial nutritional support e.g. Nasogastric/ Percutaneous Endoscopic Gastrostomy
What if I Can t get a Height or Weight? 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 length is recommended).
ALTERNATIVE MEASUREMENTS 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)
If height and weight cannot be obtained Use mid upper arm circumference (MUAC) measurement to estimate BMI category.
ALTERNATIVE MEASUREMENTS: Estimating BMI from mid upper arm circumference The subject s 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 their 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
Subjective Criteria In some patients - may not be possible to obtain height, weight or BMI In these circumstances: Other subjective criteria can be used to assist your professional judgement of the patient s nutritional risk category This is not designed to assign a score
Subjective Criteria - weight loss Step 1 - BMI Clinical impression thin, acceptable weight, overweight. Obvious wasting (very thin) and obesity (very overweight) can also be noted Step 2 - Unplanned weight loss Clothes and/or jewellery - 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.
Case Study s Practice
Mr Brown 80 year old man Weight 50kg, Height 1.7m Recently in hospital following a stroke Speech and language therapist advised - pureed diet and thickened fluids In the last month since returned to home has lost 5kg Calculate MUST score
Mrs White 72 years old Weight 50kg Weight 6 months ago was 54kg Mrs White doesn t know her height and is very unsteady on her feet Ulna length 23.5cm Mrs White is relatively well, has small portions at mealtimes What is her MUST Score
6 Steps to appropriate Nutritional Care Staffordshire Nutrition Support Guidelines Step 2 Assessment of cause of Malnutrition Ability to chew and swallowing issues Impact of medication Physical symptoms e.g. nausea, vomiting, constipation Environmental and social issues Psychological issues Tissue viability/ skin integrity
6 Steps to appropriate Nutritional Care Staffordshire Nutrition Support Guidelines Step 2- Assessment Cause of Malnutrition Consider the cause of malnutrition in Mr Brown? Mrs White?
6 Steps to appropriate Nutritional Care Staffordshire Nutrition Support Guidelines Step 3 Clear treatment goals should be documented on the patient record Target weight or target weight gain/ BMI Wound healing if relevant Weight maintenance where weight gain is unrealistic
Consider what the treatment goals could be for Mr Brown and Mrs White?
Pureed diets
Pureed diet Evidence shows that average intake of people given pureed diet which is not fortified is about 800kcals/ day Men Women Energy - EAR 2100kcals 1810kcals Protein - RNI 53.3g 46.5g COMA report Dietary reference Values for food Energy and Nutrition in the UK for older people Caroline Walker Trust Eating well for older people
What do consumers think of pureed food? (2014). Journal of Nutrition in Gerontology and Geriatrics, 33:139-159. - Food are indistinguishable from one another. - Variety is lacking. - Inconsistent appearance/texture. - Want special food for birthdays & celebrations. - Want to eat in private.
Pureed Diet Make sure puree diet is necessary consult with speech and language therapist Keep separate foods and flavours apart to make food as attractive as possible Use herbs, spices, strongly flavoured ingredients to make puree diet appetising
Improving Pureed Diets Make sure staff know what the foods are and can describe them to the resident. Use recipes to promote a consistent product. Provide a choice for sauces and condiments. Vary the temperature of the foods and the flavour (eg. sour, tangy) and account for decline in sense of smell which alters taste.
High Calorie Liquids for Pureeing Sauces cheese, parsley, dill, tartar, cheesy tomato or white sauce Creamy soups Full-fat fortified milk Full-fat yoghurt or greek yoghurt Crème Fraiche/double cream/sour cream Coconut milk (tinned)
6 Steps to appropriate Nutritional Care Staffordshire Nutrition Support Guidelines Step 4 Achieving treatment goal 3 fortified meals 2 snacks 1 pint fortified milk Make every mouthful matter
Fortifying the diet Maximise goodness in each meal Fortify diet using - high energy/ protein foods, e.g. skimmed milk powder, cream, butter, cheese, sugar, honey, oil Puree foods with milk, cream or gravy but not water
Food/Fluid fortification Food Quantity Calorie/ Protein Butter 1 pat 70 kcal Double Cream 50ml 225 kcal Olive oil 1 tbsp 99 kcal Mayonnaise 1 tbsp 128 kcal Sugar 1 tbsp 80 kcal Jam 1 tbsp 40 kcal Skimmed Milk Powder 1 tbsp 22g protein/ 118 kcal Cheese 25g 6g protein/ 104 kcal
Nourishing Drinks 1 pint of fortified milk a day 1 pint full fat milk with 4 tablespoons skimmed milk powder added Gives 600kcal and 40g protein in 1 x pint Use in milkshakes/ smoothies Malted drinks, tea, coffee made with whole milk
Ordinary Diet Food Eaten Calories Protein Breakfast Porridge (milk and water) 135 5 Mid morning Coffee 15 1 Lunch Vegetable Soup and roll 220 7 Mid afternoon Tea 15 1 Dinner Poached fish, 1 x scoop mash, peas, tinned peaches 270 31 Supper Coffee 15 1 Total 670 46
Adapted Make Every Diet Breakfast Mid morning Lunch Food Eaten Calories Protein Porridge (whole milk and 1 x tbsp double cream) Milky Coffee (200ml fortified milk) Cream of Vegetable Soup and roll with butter 330 8 200 13 335 8 Mid afternoon Tea and biscuit 85 2 Dinner Supper Poached fish, 1 x scoop mash with butter and skimmed milk powder, peas, tinned peaches and cream Malted Drink with 200ml fortified milk 490 32 225 13 Total 1665 76 Calorie Difference 995 30
Comparison of Products ½ Pint fortified milk approx 300 calories and 20g protein Ensure drink bottle 330 calories and 13g protein Ensure Crème pudding, 125g pot, 171 calories and 7g protein Thick and creamy yoghurt, 125g pot, 200 calories and 7g protein Ensure plus juce 330 calories 1 x pint orange juice 300 calories Vitamin and mineral intake should be considered
Over the Counter Complan / Meriten milk shakes and soups as powder to be mixed up Nurishment drinks in cans and bottles, ready mixed, just open and drink Vitamin and mineral intake should be considered
6 Steps to appropriate Nutritional Care Staffordshire Nutrition Support Guidelines STEP 5 Review: If food first approach has failed prescribe oral nutritional supplements Assuming patient fits prescribing criteria
GP Guidance for Prescribing (ACBS) Products are recommended on the basis that they may be regarded as drugs for the management of specified conditions Doctors should satisfy themselves that the products can be safely prescribed and that patients are adequately monitored
The criteria for prescribing Disease related malnutrition Intractable malabsorption Pre-operative preparation of malnourished patients Dysphagia Proven inflammatory bowel disease Following total gastrectomy Short Bowel Syndrome Bowel fistula Most residents will not meet these criteria
6 Steps to appropriate Nutritional Care Staffordshire Nutrition Support Guidelines STEP 6 Treatment goal met review and discontinue Review regularly to monitor Assess continued need for supplements When goals of treatment met discontinue oral nutritional supplements
Key Points Referral to dietitian if MUST 3 or 4 or if no improvement 3 meals 2 snacks- 1 pint fortified milk Make every mouthful count Food first is common sense not science Aim to increase calories in the same quantity of food
Conclusion Malnutrition can be prevented through screening Early detection leads to brighter outcomes both for residents and carers A well nourished resident could possibly need less manual assistance, be more independent Food first principles can be passed on by you to anybody in care or in the community
How to Refer to Dietetics Dietetic hub contact details: Specialist Dietetic Service Staffordshire & Stoke On Trent NHS Partnership Trust Rear Block C, Beecroft Court Beecroft Road Cannock WS11 1JP ssotp.adultdietetics@nhs.net Phone : 0300 124 0355 GoldFax: (01543) 465111 Website to access referral forms/ guidelines and make every mouthful matter information: http://www.staffordshireandstokeontrent.nhs.uk/services/dietetics_2.htm