Managing Malnutrition

1. Managing Malnutrition Andrea Ralph BSc (hons) RD Senior Medical Affairs Advisor, Nutricia

2. Identifying malnutrition Health care professionals should screen • All hospital inpatients on admission • All outpatients at there first appointments • All people in care homes on admission • All people on registration at GP surgeries • And all of the above upon clinical concern NICE Clinical Guideline 32, 2006 section 1.2.1 Recommends screening across all care settings

3. Appropriate management of malnutrition NICE Clinical Guideline 32, 2006 1.6.6 Healthcare professionals should consider oral nutrition support to improve nutritional intake for people who can swallow safely and are malnourished or at risk of malnutrition. ‘A-grade’ recommendation … should contain a balanced mixture of nutrients (including protein, energy, vitamins, minerals) … should continue until the patient is established on adequate oral intake from normal food ….take care when using food fortification as this tends to supplement energy and not other nutrients

4. Why we should manage malnutrition Adverse consequences for the patient • Muscle wasting (skeletal, cardiac, respiratory) • Reduced immune function - Increased risk of infection • Poor / delayed wound healing / pressure ulcers / reduced mobility • Apathy and depression • Reduced QOL, increased complications • Increased health care costs (Stratton et al 2003)

5. Why we should manage malnutrition Adverse consequences for the health economy People with malnutrition have higher use of health care: • More GP visits (65%) • More hospital admissions (82%) • More hospital readmissions • More deaths post-discharge • More support post-discharge (Elia 2005, Elia 2006, Stratton et al 2006)

6. NICE cost saving guidance – Dec 2009 3rd highest of 19 reviewed guidelines for potential cost saving per 100,000 people

7. Identifying and managing malnutrition http://www.bapen.org.uk/must_tool.html

8. Malnutrition risk identified – what next? • Document screening details • Identify and manage reason for decreased nutrition intake • Disease symptoms / side effects • Take action! Develop care plan (refer to local policy) • Consider: • Aims of intervention • Short term / long term goals • Route of intervention (oral / enteral / parenteral) • Practicalities • Monitor progress and adapt care plan appropriately • Weekly for all inpatients

9. Managing malnutrition

10. Enteral tube feeding • Enteral tube feeding • NG • Gastrostomy • Nutritionally complete • Wide range available for adults and children • Available in hospital and on prescription • In the community, home care nursing and delivery service provided for patients • Involve a dietitian or nutrition support team

11. Oral nutrition support Definition of : Oral nutrition support (NICE CG 32) • Practical support for people unable to feed themselves (e.g. modified feeding aids), altered meal patterns (e.g. small meals and snacks) • Fortified food with protein, carbohydrate, fat, vitamins, minerals • Dietary advice from a dietitian • Oral nutritional supplements (ONS).

12. Practicalities of improving oral intake • Assistance • Ensure food ordered is the food received • Assist with menu choices (high energy / modified texture where required) • Clear table of distractions • Ensure table, food, utensils and drinks are within reach • Offer assistance to cut up meals if needed • Adapted cutlery / plates • Altered meal patterns • Small meals and snacks (‘drip-feeding’ nutrition) • Nourishing drinks

13. What is food fortification? • Adding everyday foodstuffs to meals to increase the nutrient content, without increasing volume • Butter, oil • Full cream milk • Cheese • Skimmed milk powder • Jam • Syrup • Honey • Sugar Caution – can increase just energy and protein without micronutrients

14. Evidence – food fortification Cochrane review, 36 studies (n=2614): • Evidence for nutrition support in malnourished adults: • dietary advice • no advice and • dietary advice plus ONS in adults with malnutrition • Evidence suggests weight gain, grip strength, improved MUAC are greater with dietary advice + ONS rather than dietary advice alone ‘lack of evidence for the provision of dietary advice in managing illness-related malnutrition’ ‘dietary advice plus nutritional supplements maybe more effective than dietary advice alone or no advice’ Baldwin and Weeks 2009

15. There was insufficient evidence for NICE to assess the effect of dietary advice and / or other food strategies (snacks, food fortification) on mortality, complications and weight There was no data on the cost-effectiveness of these approaches.

16. Dietary advice from a dietitian • Individual assessment and advice • Meal pattern alteration • Food fortification • ONS • Nutritional adequacy related to condition / nutritional requirements • Clinical indication e.g. renal disease, liver disease • Ideal for individuals where first line actions have not improved nutritional intake • Preparation for discharge to home setting • Dietetic resource can vary from trust to trust • Check local policy

17. What are oral nutritional supplements (ONS)? • Produced by nutrition companies (range available) • Mostly liquids (some puddings) • Multi nutrient supplements • Most are nutritionally complete • Energy (fat and carbohydrate), protein, micronutrients) • Milk, yoghurt, juice style ready made • Ready made usually gluten and lactose free • Available in hospital and on prescription (FP10) • Supplements you make up with milk • Supplements designed specifically for children • Some disease specific

18. Practicalities of using ONS • 2 x standard 1.5 kcal/ml ONS • 600-660kcal • 24–28g protein • Consider individual preferences for flavour • (sweet, savoury, fruit preferences) • ONS can be served chilled, at room temperature or warmed • From bottle with straw, decant into cup / beaker • Add to food • Neutral / vanilla flavoured ONS in porridge, soups • Dessert style served with ice cream • Ensure patient understands why they are receiving ONS and encourage intake ONS (200-600kcal) can be used to improve clinical outcome in a range of hospitalised patients. (Stratton2007)

19. NICE review of the evidence - oral nutritional supplements • Proprietary oral nutritional supplements: • Significantly reduce mortality • Significantly reduce complications • Significantly improve weight • Functional benefits • Better energy and protein intakes in supplemented patients in all trials • Acceptable to patients

20. Age UK ‘Still Hungry to be heard’ Age UK 7 steps to end malnutrition • Hospital staff must listen to older people, their relatives and carers and act on what they say. • All ward staff must become ‘food aware’. • Hospital staff must follow their own professional codes and guidance from other bodies. • Older people must be assessed for the signs or danger of malnourishment on admission and at regular intervals during their stay. • Introduce ‘protected mealtimes’. • Implement a ‘red tray’ system and ensure that it works in practice. • Use volunteers where appropriate. www.ageuk.org.uk • Update on the campaign launched 4 years ago • - 85% of hospitals engaged with the campaign • - 55% have taken action towards the 7 steps.

21. High Impact Actions for Nursing and Midwifery • 8 ‘High impact actions’ identified by nurses and midwives • ‘Keeping nourished getting better’ focuses on: • identifying individuals at risk of malnutrition • providing good nutritional care, • stopping inappropriate weight loss and dehydration in NHS provided care. • To ensure patients are screened for malnutrition and get the right amount of nutrition and hydration needed for a speedy recovery, dietitians and nurses need to work together. http://www.institute.nhs.uk

22. Essence of Care: Benchmarks for food and drink 10 factors in the food and drink section Screening and assessment • Best Practice: People who are screened and identified at risk receive a full nutritional assessment • Screening takes place on first contact with health care providers and is repeated regularly for those at risk of malnutrition or upon clinical concern. • Validated tool such as the Malnutrition Universal Screening Tool (MUST) • A full assessment and appropriate referral is undertaken for people who are identified initially as at risk of malnutrition or as morbidly obese. • Screening, assessment and nutrition support is undertaken in partnership with people. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_119969

23. Summary Nutritional screening using a reliable and valid tool, such as ‘MUST’, is an essential first step in the management of malnutrition As part of the screening process, a plan for management of malnutrition risk should be developed There are a number of oral nutrition support strategies to improve nutrition intake Local policy should be in place for the appropriate evidence based management of malnutrition There is limited evidence for the use of dietary advice and food first strategies in clinical practice Evidence shows that ONS can improved clinical and functional outcomes which may reduce health care costs.

24. Some Key References NICE CG32. February 2006. Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Includes Costing Report. Elia M, Russell C (2009). Combating Malnutrition: Recommendations for Action. Report from the advisory group on malnutrition, led by BAPEN. Stratton RJ, Elia M. (2007). A review of reviews: A new look at the evidence for oral nutrition supplements in clinical practice. Clinical Nutrition Supplements (2); 5-23 Elia M. (2006). Nutrition and Health Economics. Nutrition (22); 576-578. NICE CG32. February 2006. Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Includes Costing Report. Elia M, Stratton R, Russell C et al. (2005) The cost of disease-related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. A report by The Health Economic Group of The British Association for Parenteral and Enteral Nutrition (BAPEN). Baldwin C and Weeks CE (2009) Dietary advice for illness-related malnutrition in adults (Review). Cochrane database of systematic reviews 2008, Issue 1. Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence-based approach to treatment. Oxford: CABI publishing, 2003.