Food and Nutrition Awareness

1. Food and Nutrition Awareness • Mary McElroy • Quality, Safety and Patient Experience Lead Nurse • Public Health Agency

2. Introduction to Promoting Good Nutrition • Balanced Diet • To highlight the importance of identifying and addressing malnutrition • Nutrients available • Nutritional screening • Use of MUST • Tips for Food First

3. Balanced Diet • Diet for people with good health, good appetite and no unintentional weight loss Aim • To achieve or maintain a healthy weight for your height • To have 3 regular meals and, with ‘ healthy’ snacks • Follow principles of the Eat Well Guide

4. Acknowledgement to Food Standards Agency NI

5. Fruit and Vegetables • Eat at least 5 portions of a variety of fruit and vegetables every day. • Fruit and vegetables should make up just over a third of the food we eat each day. • Choose from fresh, frozen, canned, dried or juiced. • A portion is 80g or any of these: • 1 apple, banana, pear, orange or other similar-size fruit, • 3 heaped tablespoons of vegetables, • a dessert bowl of salad, • 30g of dried fruit (counts as a maximum of one portion a day) • a 150ml glass of fruit juice or smoothie -counts as a maximum of one portion a day

6. Potatoes, bread, rice, pasta and other starchy carbohydrates • Base meals on potatoes, bread, rice, pasta or other starchy carbohydrates; • Just over a third of the food we eat • Choose higher-fibre, wholegrain varieties • Wholegrain cereals, wholemeal / granary/ brown / seeded breads, wholewheatpasta, brown rice, or skin on potatoes • Why choose wholegrain? • Contains more fibre than white or refined starchy food • Digest wholegrain food more slowly so feel full for longer

7. Dairy and alternative • Have some dairy or dairy alternatives (such as soya drinks); choosing lower fat and lower sugar options • Source of protein and calcium • Choose lower fat and lower sugar products where possible • 1% fat milk • Semi-skimmed milk • Reduced fat cheese • Unsweetened, calcium-fortified dairy alternatives

8. Beans, pulses, fish, eggs, meat and other proteins • Eat some beans, pulses, fish, eggs, meat and other proteins • Include 2 portions of fish every week, one of which should be oily

9. Oils and spreads • All types of fat are high in energy and should be limited in the diet. • Generally we are eating too much saturated fat and need to reduce. • Choose lower fat spreads, as opposed to butter, to reduce saturated fat. • Unsaturated fats are healthier fats for example vegetable oil, rapeseed oil and olive oil. • Choose unsaturated oils and spreads and eat in small amounts

10. Foods and drinks high in fat, salt or sugar • If consuming foods and drinks high in fat, salt or sugar have these less often and in small amounts • Chocolate, cakes, biscuits, • full-sugar soft drinks and ice-cream • Check the label and avoid foods which are high in fat, salt and sugar

11. Hydration • Drink 6-8 glasses of fluid every day • Choose water, lower fat milk and sugar-free drinks including tea and coffee • Fruit juice and smoothies also count towards your fluid consumption, and will count towards 1 of 5 A Day • Source of free sugars • Limit consumption to no more than a combined total of 150ml per day.

12. Front of pack labelling • High, medium or low • Fat, saturated fat, sugars and salt • For a healthier choice, choose more greens and ambers and fewer reds

13. Key Recommendations • Base meals on starchy carbohydrate foods, higher fibre versions • Eat lots of fruit and vegetables, at least 5 portions daily • Eat more fish – including a portion of oily fish each week • Cut down on saturated fat and sugar • Eat less salt • Get active and be a healthy weight • Drink plenty of water • Don’t skip breakfast

14. Further information https://www.bda.uk.com/foodfacts/home https://www.food.gov.uk/northern-ireland/nutritionni/ https://www.bda.uk.com/foodfacts/HealthyEating.pdf

15. Any questions so far?

16. Malnutrition • Estimated it affects over 3 million people in UK • 1.3 million over the age of 65 • 25-34% patients admitted to hospital at risk of malnutrition • 30-42% patients admitted to care homes at risk of malnutrition • 18-20% patients admitted to mental health units at risk of malnutrition

17. Cost of Malnutrition • BAPEN estimated cost of £13 billion (2011-12) • Increased dependency • Increased GP visits • Increased prescription costs • Increased referrals to hospital/care homes • Increased complications • Increased readmissions to hospitals

18. Malnutrition Meeting the body’s needs for energy and nutrients is essential for good health. Intakes of energy and/or nutrients below or in excess of needs over time time can effect health and lead to health problems. Malnutrition is a term which covers problems of both under and over nutrition.

19. Symptoms of malnutrition • Loss of appetite • Weight loss (loose clothing, rings dentures) • Tiredness/lack of energy • Reduced ability to preform normal tasks • Reduced physical performance • Altered mood • Poor concentration

20. Consequences of Malnutrition • Malnutrition affects every system in the body and always results in increased vulnerability to illness, increased complications and in very extreme cases even death. • Some examples • Immune system – reduced ability to figt infection • Muscles – inactivity, reduced ability, falls, pressure ulcers • Impaired wound healing • Kidney – inability to regulate salt and fluids (dehydration/over-hydration) • Brain – apathy, depression, introversion, self-neglect

21. Under nutrition Under nutrition occurs when is there is a deficiency of one or more nutrients. It may be mild or severe. Mild forms of under nutrition exists in the UK, e.g. micronutrient deficiency. Severe under nutrition is rare in countries like the UK, but can be common in some developing countries. The body may adapt to a short period of under nutrition. Some nutrients, such as fat-soluble vitamins, are stored in the body and can be used if the diet does not provide enough.

22. Protein Protein is essential for growth and repair and keeping cells healthy. Protein also provides energy: 1 gram of protein provides 4 kcal (17 kJ).

23. Fat Fat provides fat-soluble vitamins A, D, E and K, and is necessary for their absorption. It is also important for essential fatty acids the body cannot make. Fat provides a concentrated source of energy: 1 gram of fat provides 9 kcal (37 kJ). Foods that contain a lot of fat provide a lot of energy.

24. All foods provide different types of fatty acids in varying proportions. Butter is often described as a ‘saturated fat’ because it has more saturated fatty acids than unsaturated fatty acids. Most vegetable oils are described as ‘unsaturated fats’ as they have more mono- and polyunsaturated fatty acids than saturated. Most saturated fats are solid at room temperature and tend to come from animal sources.  Most unsaturated fats are liquid at room temperature and are usually from plant sources.

25. Micronutrients There are two types of micronutrients: vitamins; minerals. Vitamins and minerals are needed in much smaller amounts than macronutrients. Their amounts are measured in milligrams (mg) and micrograms (μg). (1mg = 0.001g) (1μg = 0.001mg).

26. Vitamins There are two groups of vitamins: • fat-soluble vitamins, which can be stored in the body, e.g. vitamins A and D. • water-soluble vitamins, which cannot be stored in the body and are therefore required daily, e.g. B vitamins and vitamin C.

27. Minerals Minerals are inorganic substances required by the body in small amounts for a variety of different functions. The body requires different amounts of each mineral. People have different requirements, according to their: age; gender; physiological state (e.g. pregnancy).

28. Calcium The body contains more calcium than any other mineral. It is essential for a number of important functions such as the maintenance of bones and teeth, blood clotting and normal muscle function. Did you know? The skeleton contains about 99% of the body’s calcium with approximately 1kg present in adult bones.

29. Iron Iron is essential for the formation of haemoglobin in red blood cells. Red blood cells carry oxygen and transport it around the body. Iron is also required for normal metabolism and removing waste substances from the body. Did you know? There are two types of iron; one from animals sources and the other from plant sources.

30. Iron in the diet A lack of iron in the diet means that the stores in the body will run out. This can lead to anemia. Women and teenage girls need to ensure they have enough because their requirements are higher than those of men of the same age due to menstruation. Did you know? More than 2 billion people worldwide suffer from iron deficiency anaemia, making it the most common nutritional deficiency.

31. Sodium Sodium is found in all cells and body fluids. It is needed for regulating the amount of water and other substances in the body. Did you know? Sodium is a component of table salt, known as sodium chloride (NaCl).

32. Over nutrition Over nutritionis a problem usually associated with developed countries, such as the UK. The most common form of over nutrition is having an energy intake in excess of needs, resulting in overweightand obesity. Very high intakes of minerals and fat soluble vitamins (more can usually be obtained from food sources alone) can be toxic. This is because they are stored in the body, e.g. vitamin A is stored in the liver.

33. Obesity Being morbidly obese is associated with a 12-fold increase in mortality in 25-35 year olds when compared to lean individuals. A recent report estimated that in England 30,000 deaths per year are obesity-related. On average, each person whose death could be attributed to obesity lost nine years of life. Obesity is the most important dietary related factor in chronic diseases such as cancer, cardiovascular disease and type 2 diabetes. Obesity is second only to smoking as a cause of cancer.

34. Risk of malnutrition • The risk of malnutrition is increased by: • increased requirements. It is more difficult to meet nutritional needs during periods of increased requirements. For example, some women have very high requirements for iron, e.g. if their menstrual losses are high; if they cannot obtain enough in their diet they may develop anaemia; • reduction in availability of food. Famineis an extreme example; • medical conditions.Some may affect food intake of the absorption of nutrients from foods.

35. Risk of malnutrition The risk of malnutrition is increased by: • restricted range of foods. A diet based on a narrow range of foods is more likely to lack nutrients. For example, in countries where maize is the staple food and few others are eaten, diets may lack niacin, a B vitamin which is poorly absorbed from maize. As a result, the deficiency disease pellagra can occur; • income. Lack of money may make it difficult to purchase an adequate diet. Cultural practices may mean that not everyone in a family gets a fair share of the food available.

36. Risk of malnutrition • The risk of malnutrition is increased by: • other substances in foods.Very high intakes of some substances, for example dietary fibre, reduce absorption of some nutrients from food; • psychological problems. Some may affect food intake; • unusual dietary habits.These may lead to over nutrition, e.g. taking toxic amounts of vitamin/mineral supplements or under nutrition e.g. having a slimming diet that does not provide sufficient nutrients.

37. Nutritional screening • The Promoting Good Nutrition Strategy (DHSSPS, 2010)1 identified the Malnutrition Universal Screening Tool (MUST) as the screening tool of choice to identify those adults who are at risk of malnourishment or who are malnourished. • Nutritional screening is the first step in the identification of malnutrition. The screening process enables detection of significant risk of malnutrition and supports the implementation of a clear plan of action, such as simple dietary measures or referral for expert advice. • For further information on MUST guidance and the MUST tool, visit: http://www.bapen.org.uk/screening-for-malnutrition/must/introducing-must

38. These guidelines and resources were developed by the Promoting Good Nutrition Resource Development Steering Group in 2013, updated by the Promoting Good Nutrition Malnutrition screening and intervention task group 2018

39. What nutritional screening is not: • It is important to recognise that using MUST is NOT • • a replacement for professional judgement and decision making • • the only reason to refer a patient for dietetic intervention • • an indicator to stand down a nutritional care plan that is clinically effective • • to be used in isolation from other multi-factorial clinical information.

40. Guideline 1 • All* adult patients/clients must be screened to identify those who are malnourished or at risk of becoming malnourished using MUST (including pre-MUST questions, if applicable) by a competent person*(Adapted from NICE 2017 Guidance) • *A competent person is one who has been trained and is competent in the use of MUST

41. Use the appropriate MUST template • • MUST template • - for the hospital setting; • - for the community setting; • - for the care home setting; • NB Nutritional screening and repeat screening should be determined based on the level of risk or clinical concern. • *

42. There are exempt from MUST screening andtheir nutritional groups of patients/clientswhoare needs will be managed via other routes. • pregnant women • individuals undergoing dialysis treatment • individuals receiving enteral or parenteral nutrition • individuals in critical care units • individuals who may be in the last weeks and days of life (GAIN, 2013). • Note: some patients with e.g. heart failure, liver disease or who have fluid overload can appear to have a low MUST score and this should be taken into account when making the assessment, as they may be at risk of malnutrition.

43. Guideline 2 • Action to be taken with the following MUST screening results based onBAPEN guidance (2003)

44. Low Risk -MUST Score 0 For those patients/clients identified as low risk/MUST score of 0 and in the case of routine clinical care it is recommended that ‘MUST’ is repeated as follows, unless otherwise clinically indicated: • hospitals – weekly • care homes – monthly • community caseload – annually • general population – annually for special groups e.g. elderly>75 years.

45. Medium Risk – MUST Score 1 • For those patients/clients identified as medium risk/MUST score of 1 the practitioner should: • • investigate and address causes of nutritional problems including social issues e.g. nausea, infection, inability to prepare food, requires assistance with meals • • provide Food First Advice leaflets in the community setting or implement Food First advice • • repeat MUST screening as follows, unless otherwise clinically indicated: • - hospitals – weekly • - care homes – monthly • - community caseload – every 2-3 months • • if improving continue until low risk • • if deteriorating consider treating as high risk e.g. MUST score remains 1 and is accompanied by any one of the following: reducing appetite; further unintentional weight loss/no weight gain; worsening medical condition or dysphagia.

46. High Risk – MUST Score > 2 • For those patients/clients identified as high risk/MUST score of >2 the practitioner should: • • investigate and address causes of nutritional problems including social issues e.g. nausea, infection, inability to prepare food, requires assistance with eating and drinking • • provide Food First Advice leaflets in the community setting or implement Food First advice in the care home setting. In addition, ensure compliance with previous ‘food first’ advice • • refer the patient/client to a Dietitian • • recheck MUST screening as follows, until under the care of the Dietitian, unless otherwise clinically indicated: • - hospitals – weekly • - care homes – monthly • - community caseload – monthly

47. NB: While a patient is on a Dietitian’s active caseload, repeat screening will only be required as directed by the Dietitian. Repeat screening should resume as above when the patient is discharged from dietetic care. • Nutrition care plans can be recorded on the relevant MUST templates and should be tailored to the individual patient’s/client’s needs. The comments boxes are designed to enable practitioners to implement person-centred nutrition care planning.

48. Guideline 3 • The patient’s/client’s MUST score should be communicated as the individual transfers across the relevant care setting to ensure their individualised nutrition care plan is maintained.