Malnutrition Information for Carers (Guidelines for use in North Norfolk, Norwich and South Norfolk) Produced in partnership with the NNUH Dietetics Services
What is malnutrition? Malnutrition is a condition which happens when you don t get the correct amount of nutrients from your diet. Here we re looking at people who may not be getting enough nutrients, rather than people getting too much. Malnutrition can cause health problems such as an increased risk of falls, illness, infection, and slower wound healing. You can help by adding extra calories to normal foods and giving nourishing drinks and snacks between meals. This is known as food first. What is food first? Food first is a really practical way of managing malnutrition and the accompanying unwanted weight loss and should stop or reduce once a healthy weight is achieved. The calorie content of meals can be boosted with natural ingredients and highenergy snacks. This can be done by adding natural ingredients for example, skimmed milk powder, butter, cream, cheese, sugar, honey and jam. If a person is already buying high-calorie nutritional supplements, why not try food first as a more varied and natural way of increasing nutrition? 2
How can I tell if someone is malnourished? Some common signs of malnutrition are: Unplanned weight loss, causing loose clothes, belts, jewellery or dentures Tiredness and lethargy Changes in mood Loss of appetite Loss of strength How to measure malnutrition? Malnutrition can be measured by using a suitable screening tool e.g. MUST (short for Malnutrition Universal Screening Tool ). You can find out more on the official MUST site at www.bapen.org.uk, and there are lots of leaflets and training resources on the BAPEN website that you can use to understand nutrition better. MUST assesses malnutrition using Body Mass Index (BMI) and recent unplanned weight change, and many care homes use MUST monthly to monitor residents. If you are caring for someone in their own home, you can do this too just make sure the weighing scales are fairly accurate by weighing yourself first! Once you have the MUST score, you can work out what to do to help. If you re worried about weight loss, but can t get the information you need to perform a MUST assessment, start recording weight and start treating with food first. If you re still worried after a month of food first seek the opinion of your GP or Nurse Practitioner. 3
What do I do once I have calculated the total MUST score (the malnutrition risk)? These are the local NHS guidelines on how to act on a MUST score, and are recommended in place of the general guidance within the MUST Step 5. They apply in areas covered by the Norfolk and Norwich University Hospital. This is where Food First comes in, if needed. Score 0 is low risk : Continue the person s normal diet. In a care home setting, repeat the assessment next month. For a person who is following Food First, once their BMI rises above 20, they should begin reducing or stopping any prescribed high-calorie supplements to avoid over-nutrition. However, they may still need to continue with regular snacks and some fortified food to maintain a natural, stable weight. It s best to change diet gently over the course of a month or longer, and to weigh at least monthly while changing. Score 1 is medium risk : Monitor weight loss, measure MUST score regularly, i.e. monthly, or sooner if person s condition changes. Encourage small frequent meals and snacks with high energy and protein food and fluids. Aim for 400-600 extra kilocalories a day above their normal diet. Keep a food diary for 3 days (see template in Appendix A). If the person is still losing weight after two weeks, offer them fortified milky drinks or over-the-counter powdered nutritional supplements made up with full-fat milk. Score 2 is high risk : Monitor weight loss, measure MUST score regularly, i.e. monthly, or sooner if the person s condition changes. Encourage small frequent meals and snacks with high energy and protein food and fluids. Aim for 400-600 extra kilocalories a day above their normal diet. Keep a food diary for 3 days (see template in Appendix A). Continue to offer over the counter powdered nutritional supplements made up with full-fat milk or fortified milky drinks If still losing weight after 4 weeks also ask the person s healthcare professional to consider referring to a dietitian. Note: Swallowing Difficulty: If the person you are caring for has difficulty swallowing (dysphagia), please follow the advice of your Speech and Language Therapist. 4
Things that might stop people eating enough Painful teeth or badly-fitting dentures Good tooth-brushing twice a day is important for oral hygiene and comfort Do they need dental treatment, or more soft food and purees in their diet? Some people can t sense the temperature of food and may have burnt their mouths, causing pain when eating. Can you help by checking the temperature is not too hot when served? Difficulty or pain when swallowing Speech and Language Therapists can carry out swallowing assessments, and can help plan how to eat Physical difficulty handling knife / fork / spoon / cup Chopped-up food eaten with a spoon may be easier than using a knife and fork Maybe a half-full cup would be easier to lift than a full one Special cutlery for shaky-hands, high-sided plates and non-spill cups exist Finger foods like sandwiches and slices of cooked food may be easier An Occupational Therapist may be able to advise on aids to make it easier to handle food and drink and cutlery Changes that make it difficult to shop or cook Could a friend or relation shop online? Could the council s social services offer help with eating and drinking? Changes in sense of smell or in food preferences, without a similar change in food offered For example some older people with dementia lose interest in savoury food but accept sweet food Some people find stronger-tasting food is easier to swallow, and they may find alternating different tastes from mouthful to mouthful helps Uncomfortable eating environment. Is the person comfortable and upright? If it s hard to find a comfortable position for them, a seating assessment can be made by Occupational Therapists Poor lighting, temperature, space and sounds distractions from eating Is the person feeling rushed / stressed / embarrassed / confused? Allow time to eat calmly and give encouragement 5
Unappetising appearance of food. A person with dementia may find it hard to recognize food and drinks. Clear colours against a simple non-patterned background, and a bright nonpatterned mug (or a glass so the person can see the drink inside) are worth trying. Are meals presented when the person is sleepy, or too close to the last food, or too close to a nutritional drink? Are meals too big? A person with low appetite would gain more from 6 small meals spaced out through the day than from 3 large meals. Snacks not available when person is ready. How about putting a snack station within easy reach, with some ready-to-eat snacks? Dehydration can reduce appetite An average adult might be expected to drink 1.5 litres to 2 litres each day. Remember that milky drinks and fruit smoothies are nutritious ways to get fluid intake. Low-fat or low-calorie foods prevent a low-appetite person eating an equivalent quantity of nourishing food. 6
Food First -Top Tips for Someone Trying to Gain Weight Eating little and often, with high-calorie snacks between meals. Include protein with each meal e.g. meat, fish, cheese, eggs, beans, nuts and milk. Choose favourite foods, these can often tempt someone with poor appetite. Drink mostly after or between meals. A small drink with meals leaves room for food at mealtimes. Ready meals, served with vegetables from the freezer can be a quick and nutritious meal. Fortifying or enriching food is a great way of boosting calorie intake and can be achieved by simple additions to normal meals. Foods that are important for giving the body energy are measured in kilocalories (kcal). Take a look at the food diary below, does it look like a typical day for someone you care for? Meal time Food Eaten Kilocalories Breakfast Mid-morning Lunch Mid-afternoon Porridge made with semi skimmed milk and water (45g of oats + 200ml water & 60 ml of milk) Cup of coffee, semi skimmed milk, no sugar (40ml milk) Fish in parsley sauce (140g), mashed potatoes (120g low-fat), peas (2 heaped tablespoons). Tinned peaches (half a 400g tin) Cup of tea with semi skimmed milk, no sugar 190 20 215 100 20 Supper Half a tin of thin vegetable soup and a 265 buttered roll (medium, with 7g butter Evening Cup of tea with 40ml semi skimmed milk, no sugar 20 Total 830 This looks like a lot of food, but look at the total number of kilocalories only 830! 7
Fortifying Food You can add extra calories to food and drinks by adding high calorie ingredients here are some suggestions: Fortified milk: 1 pint full fat milk whisked with 4 heaped tablespoons skimmed milk powder provides 580 kilocalories with low-cost ingredients particularly if you use supermarket own-brand skimmed milk powder. It s high protein too. Just add: Cheese Small matchbox size piece 125kcal Skimmed milk powder One heaped tablespoon 50kcal Sugar, Jam or Honey* One heaped teaspoon 20kcal Extra fats (butter, margarine, oils or mayonnaise) One heaped teaspoon 35kcal Double cream One heaped Tablespoon 70kcal Sauces aim for milky/ creamy sauces. Breakfast cereals Cereal or porridge Mashed potato Sauces Pasta dishes Porridge Puddings Toast and bread Mashed potato Pizza Mashed potato Hot drinks Sauces Soups Omelettes Sauces Milkshakes or smoothies Glaze vegetables Puddings Scrambled eggs Mashed potatoes Beans on toast Custard Glaze vegetables Cakes Milk puddings Ice cream Cereal & porridge Creamy soups Milkshakes or smoothies Milkshakes or smoothies Fruit *Note on Diabetes: If you had previously been advised to limit your intake of sugars due to diabetes, please seek advice before adding extra sugar, jam or honey. *Note on Dysphagia: If the person you are caring for has difficulty swallowing (dysphagia), please follow the advice of your Speech and Language Therapist, as having the recommended thickness and texture is vitally important. 8
Snacks How many calories are in your snacks? Snacks worth more than 200 Kcal Snacks worth under 200 Kcal Mini pack of biscuits (e.g. bourbon 40g) 200kcal Plain biscuits (2 x 20g) 140kcal Thick n creamy yoghurt (115g) 200kcal (and soft) Small individual trifle (105g) 150kcal Two slices hot buttered toast (each 27g bread & 7g butter) Cereal with fortified milk (30g oats or 2 Weetabix with 150ml) Syrup sponge with custard or choc sauce (95g) 300kcal 270kcal (and soft) 340kcal (and soft) Jam tart (35g) 2 Cocktail sausage rolls (30g) 7 boiled sweets or half packet fruit pastilles 140kcal 130kcal 65kcal Chocolate buttons (70g pack) 378kcal Small sandwich 1 slice bread & butter with ham, cheese spread or pâté. 140kcal Matchbox size piece of cheese with 14g butter and two crackers 225kcal 9
Remember our 830 kilocalorie food diary? Here is a similar enriched one, using the Top Tips. Don t forget the drinks they should add up to 1.5 to 2 litres too. Meal time Food Eaten Kilocalories Breakfast Mid-morning Lunch Mid-afternoon Supper Evening Porridge made with whole milk (45g of oats + 260ml milk) Large milky coffee made with whole milk (containing 210ml milk) Fish in parsley sauce (140g), mashed potatoes (120g / whole milk & 10g butter), peas (2 heaped tablespoons, with 5g butter). Tinned peaches (200g) & double cream (1 tablespoon) Cup of tea with 40ml whole milk and a digestive biscuit Half a tin Cream of chicken soup with a tablespoon of double cream and a buttered roll (7g butter) Malted milk biscuit with mug of fortified whole milk (half-pint) 330 135 315 170 105 350 45 290 Total 1740 Adding full fat milk, butter, a little cream and a biscuit along with a fortified drink has boosted the energy content to 1740 kilocalories, more than double! 10
Appendix A: 3 Day Food Diary Residents name: Diary start date: Food offered Day 1 Day 2 Day 3 Breakfast Mid-morning Snack Lunch Mid-afternoon snack Dinner Bedtime Please enter the details of all food and drink on the left and use the key below to enter how much was eaten. A = All ½ = Half LH = Less than half MH = More than half R = Refused N = None 11
Appendix B: Useful websites The BAPEN organisation Hosts the MUST tool for measuring malnutrition risk http://www.bapen.org.uk/ The British Dietetic Association (BDA) Very useful for their Food Factsheets https://www.bda.uk.com/ Vegetarian For Life a charity seeking to improve the quality of life of the UK s older vegetarians and vegans. They have published a Catering for Older Vegetarians and Vegans guide, and Nutrition for Older Vegetarians and Vegans guide. www.vegetarianforlife.org.uk The Caroline Walker Trust A charity aiming to improve public health through good food. They publish several guides, including Eating Well for Older People and Eating Well for Older People with Dementia www.cwt.org.uk Northern Health and Social Care Trust Publishes: Eating well for people with Dementia a guide for carers www.northerntrust.hscni.net Alzheimer s Society Publish a wide range of factsheets to help support dementia carers and sufferers www.alzheimers.org.uk NELCSU (Anglia) Prescribing and Medicines Management Team Malnutrition Information for Carers Version: 1.1 Issued: February 2017 Review: July 2017 12