Christine Russell SRD on behalf of MAG

1. Christine Russell SRDon behalf of MAG

3. Understanding malnutrition No universally accepted definition but the following working definition is suggested �A state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body structure and function and clinical outcome�

4. Malnutrition is undetected and untreated Hospitals inpatients 70% unrecognised (Kelly et al, 2000) 62% unrecognised (Mowe et al 1991) Hospital outpatients 45-100% of patients unrecognised (Miller et al 1990) Nursing homes Almost 100% of patients unrecognised (26 nursing homes) (Abbasi & Rudman 1990) Community e.g 15-50% of children with failure to thrive are unrecognised (Wright et al 1998; Bachelor 1990)

5. Prevalence of malnutrition % underweight adults (BMI<20kg/m2 ) living freely in the community, hospital & residential accommodation Elia/MAG 2003 General population: England 5.2% Scotland 5.5% Wales 5.0% Patients in the community: Major surgery previous 6 wks >10.6% Chronic diseases 12.2% Residential accommodation: In UK >65 yrs 16.0% In Scotland >65yrs 29.0% Hospital: 13-40%

6. Percentage of people aged 65+ at medium/high risk of malnutrition

9. Consequences of malnutrition Increased morbidity Increased length of stay Increased dependency Increased mortality Increased costs of care

10. Increased health care utilisation with malnutrition risk (Stratton et al 2002)

11. Financial issues Up to �266m (1992 figs) could be saved by NHS each year if malnourished patients identified and treated Malnutrition in patients >65yrs costs ~�2-4b more than well nourished elderly Malnourished elderly more likely to be admitted to hospital and discharged to nursing homes Undernutrition costs NHS more than obesity

12. Why screen for malnutrition? Malnutrition is frequently unrecognised and untreated Effective management of malnutrition reduces the burden on health & care resources Regular screening is the only way that malnourished individuals can be identified and appropriate action taken

13. What has this got to do with me? Nutrition/malnutrition now a priority in policy initiatives and practice 1992 A Positive approach to nutrition as treatment (King Fund Centre) 1996 Malnutrition in Hospital (BDA) 1997 Eating Matters (DH) 1997 Hungry in Hospital (Ass Community Health Councils) 2000 Managing Nutrition in Hospital: a recipe for quality (DH) 2000 Detection and Management of Malnutrition (BAPEN) 2001 The National Service Framework for Older People (DH) 2001 Essence of Care (DH) 2001 Acute Hospital Portfolio: Hospital Catering report (DH) 2001 National Nutritional Audit of Elderly Individuals in Long-term Care (Scottish Executive � CRAG) 2001 National Care Standards Commission / National Minimum Standards for Older People in Care Homes (DH) 2002 Food and Nutritional Care in Hospitals: how to prevent undernutrition (Council of Europe) 2002 Nutrition & patients: a doctors responsibility (Roy Col Phys) 2002 Improving Health in Wales, Nutrition and Catering Framework. (WAG) 2003 Food , Fluid and Nutritional Care in Hospitals (NHSQIS) 2004 PEAT (DH)

14. What has this got to do with me? Nutrition/malnutrition now a priority in policy initiatives and practice 1992 A Positive approach to nutrition as treatment (King Fund Centre) 1996 Malnutrition in Hospital (BDA) 1997 Eating Matters (DH) 1997 Hungry in Hospital (Ass Community Health Councils) 2000 Managing Nutrition in Hospital: a recipe for quality (DH) 2000 Detection and Management of Malnutrition (BAPEN) 2001 The National Service Framework for Older People (DH) 2001 Essence of Care (DH) 2001 Acute Hospital Portfolio: Hospital Catering report (DH) 2001 National Nutritional Audit of Elderly Individuals in Long-term Care (Scottish Executive � CRAG) 2001 National Care Standards Commission / National Minimum Standards for Older People in Care Homes (DH) 2002 Food and Nutritional Care in Hospitals: how to prevent undernutrition (Council of Europe) 2002 Nutrition & patients: a doctors responsibility (Roy Col Phys) 2002 Improving Health in Wales, Nutrition and Catering Framework. (WAG) 2003 Food , Fluid and Nutritional Care in Hospitals (NHSQIS) 2004 PEAT (DH)

15. Prevalence of malnutrition using different tools

16. Definitions Nutritional screening Rapid, simple general procedure done at first contact with subject to detect risk of malnutrition, done by nurses, doctors or other HCWs Nutritional Assessment Detailed, more specific in depth evaluation of subject�s nutritional status, done by those with nutritional expertise

17. The Malnutrition Advisory Group (MAG) The Malnutrition Advisory Group (MAG) is an independent standing committee of BAPEN Formed in 1998 with a multidisciplinary membership of healthcare professionals

18. Aims of the MAG Raise awareness of malnutrition among health and social care professionals, policy makers and the media Ensure health & social care professionals give priority to combating malnutrition Communicate the benefits of timely use of nutritional supplements Develop a screening tool & produce definitive guidelines for the detection and management of malnutrition

19. Why is screening a �MUST�?Malnutrition Universal Screening Tool To provide a validated, reliable, and practical tool for nutritional screening To develop a tool to allow comparable nutritional screening across different care settings by different health professionals To identify individuals who are undernourished or obese

20. Development of the �MUST� The MAG community screening tool (launched in 2000) adapted and extended to care homes and hospitals Validated and piloted across all care settings Alternative methods of measurement determined Field tested for overall look and �use-ability�

21. Where the �MUST� can be used

25. Components of �MUST� Flow chart � visual layout of procedure BMI chart and weight loss tables� showing clearly the risk scores Alternative measurements Explanatory notes Evidence based, referenced report

27. The 5 �MUST� Steps Body Mass Index (BMI) Score � height and weight Weight Loss Score - unplanned weight loss in past 3-6 months Acute Disease Effect Score Overall Risk of Malnutrition - Add Scores Results: 0 = low risk; 1 = medium risk; 2 or more = high risk Subjective judgement if measurements not possible 5. Recommended Management Guidelines � to form appropriate care plan in line with local policy

28. BMI (kg/m2) Indicates chronic protein-energy status Protein-energy malnutrition is �probable� at a BMI <18.5 kg/m2 and �possible� at a BMI of 18.5-20.0 kg/m2 Adverse physiological and clinical effects occur with a BMI <20 kg/m2 BMI is a simple, objective and reproducible measurement ? Age specific BMI is an attractive index because it is linearly related to fat and inversely related to the proportion of body weight due to lean tissues which carry out a variety of physiological functions and the proportion of body weight due to body fat, which is a risk factor for premature death. Relationship between BMI and body composition is only approx and is affected by gender, age and race. BMI is an index relating to risk and is not a diagnostic tool for malnutrition. It should be used to provide an approx guide to the probability or risk of PEM rather than to identify malnutrition per se. BMI has been recorded in a wide range of studies in relation to mortality and body function in a variety of circumstances. This makes possible a comparison of extensive amounts of data obtained from different parts of the world and different healthcare settings. ASPEN Board of Directors (2002)suggest 18.5kg/m2 to indicate underweight in their report on evidence based best approach to practice of nutritional support. The Office of Population Census and Surveys in the UK uses <20 to indicate underweight even in people >75yr. BMI is an attractive index because it is linearly related to fat and inversely related to the proportion of body weight due to lean tissues which carry out a variety of physiological functions and the proportion of body weight due to body fat, which is a risk factor for premature death. Relationship between BMI and body composition is only approx and is affected by gender, age and race. BMI is an index relating to risk and is not a diagnostic tool for malnutrition. It should be used to provide an approx guide to the probability or risk of PEM rather than to identify malnutrition per se. BMI has been recorded in a wide range of studies in relation to mortality and body function in a variety of circumstances. This makes possible a comparison of extensive amounts of data obtained from different parts of the world and different healthcare settings. ASPEN Board of Directors (2002)suggest 18.5kg/m2 to indicate underweight in their report on evidence based best approach to practice of nutritional support. The Office of Population Census and Surveys in the UK uses <20 to indicate underweight even in people >75yr.

29. BMI categories for chronic protein energy status Roy Coll Phys Lond, MAG(BAPEN) BMI (kg/m2 ) Weight category -------------------------------------------------------------- <18.5 Underweight (probable PEM*) 18.5-20 Underweight (possible PEM*) 20-25 Desirable weight 25-30 Overweight >30 Obese * PEM = Protein-Energy Malnutrition

30. Step 1: BMI Obtain weight and height Calculate BMI or use BMI chart provided to get score Use recalled height and weight or recommended alternative methods of measurement if actual values cannot be obtained

31. BMI Score BMI Score >20 kg/m2 0 18.5-20 kg/m2 1 <18.5 kg/m2 2 >30 kg/m2 ( obese ) 0

32. Unintentional weight loss over 3-6 months <5% body weight: normal intra-individual variation 5-10% body weight: of concern decrease in voluntary physical activity increase in fatigue less energetic >10% body weight: of significance changes in muscle function disturbances in thermoregulation poor response or outcome to surgery and chemotherapy Clinical studies have demonstrated that recent weight change is one of the most important components of malnutrition screening tools. It contributes to clinical outcomes independently to BMI. Rapidity of weight loss is probably more important than actual time periodClinical studies have demonstrated that recent weight change is one of the most important components of malnutrition screening tools. It contributes to clinical outcomes independently to BMI. Rapidity of weight loss is probably more important than actual time period

33. Step 2: Weight Loss Score Unplanned weight loss over 3 � 6 months Indicates acute or recent-onset malnutrition Score <5% body weight: 0 5-10% body weight: 1 >10% body weight: 2

34. Step 3: Acute Disease Effect Patients who have had or are likely to have no nutritional intake for more than 5 days Most likely to apply to patients in hospital Add 2 to score

35. Step 4: Overall Risk of Malnutrition Total of scores from Steps 1, 2 and 3 Document score 0 = Low risk 1 = Medium risk 2 or more = High risk

36. Alternative measurements Measure between the point of the elbow (olecranon process) and the midpoint of the prominent bone of the wrist (styloid process). Use the left arm if possible.Measure between the point of the elbow (olecranon process) and the midpoint of the prominent bone of the wrist (styloid process). Use the left arm if possible.

37. BMI Category The subject�s left arm should be bent to 90� angle with the upper arm held parallel to the body. Measure the distance between the bony protrusion on the shoulder and the point of the elbow. Mark the mid point. Ask the subject to let the arm hang loose and measure around the upper arm at the mid point. Make sure the tape is snug but not tight.The subject�s left arm should be bent to 90� angle with the upper arm held parallel to the body. Measure the distance between the bony protrusion on the shoulder and the point of the elbow. Mark the mid point. Ask the subject to let the arm hang loose and measure around the upper arm at the mid point. Make sure the tape is snug but not tight.

38. Subjective Criteria If height or weight cannot be obtained, consider the following subjective criteria : BMI Is subject , thin acceptable weight or overweight? Weight loss Are clothes or jewellery loose? Has there been a change in appetite? Any swallowing difficulties? Underlying disease or psychosocial / physical disabilities Acute disease No nutritional intake >5 days

39. The old ones are the best

40. Step 5: Recommended management guidelines Low risk Repeat screening ( weekly,monthly,annually) Medium risk Document food intake for 3 days, if no improvement follow local policy Re screen (weekly,monthly) High risk Seek expert advice, monitor and review (weekly, monthly) in line with local policy

42. Care plan Set aims and objectives Treat underlying conditions Improve nutritional intake Monitor and review Reassess subjects at nutritional risk as they move through care settings

43. Nutritional interventions Provide help and encouragement with eating and drinking Offer tasty, nutritious and attractive meals Provide pleasant environment in which to eat Consider oral nutritional supplements if unable to meet requirements Monitor and review

44. Oral Nutritional Support for the �at risk� patient Good food Dietary counselling and fortification Oral nutritional supplements (ONS)

45. Oral Nutritional Support for the �at risk� patient Good food Dietary counselling and fortification Oral nutritional supplements (ONS)

46. Maximise food intake Help with feeding Help with shopping or cooking Ensuring good dentition Suitable feeding equipment Avoiding unnecessary NBM Multidisciplinary involvement

47. Dietary counselling Very few trials (< 10) have shown that dietary counselling can improve food intake (energy and protein intakes) and nutritional status (body weight) in the treatment of malnutrition Most trials do not mention who did the counselling, what form this took (written, oral instructions/advice), compliance with advice

48. Dietary counselling Very few trials (< 10) have shown that dietary counselling can improve food intake (energy and protein intakes) and nutritional status (body weight) in the treatment of malnutrition Most trials do not mention who did the counselling, what form this took (written, oral instructions/advice), compliance with advice

49. Food �fortification� Oil Cream Sour cream Butter Milk Cheese Sugar Skimmed milk powder Commercial CHO/protein powder or liquids

50. Food �fortification� What do we want to achieve? Improve the intake of a range of nutrients? Improve recovery?

51. Dietary advice and food fortification in COPD ( Weekes 2004) Malnourished patients with COPD Dietary advice plus milk powder for 6mths Written advice on food fortification Followed up for one year

52. Dietary counselling or supplements A Cochrane review (4 trials) (Baldwin 2002) Supplemented patients had significantly greater weight gain (or less loss) and significantly greater energy intakes than patients given dietary counselling, over 3 months These were relatively short term studies and there is a need for more comparative studies that are well designed. The efficacy of using dietary counselling to improve outcome has not been investigated either. These were relatively short term studies and there is a need for more comparative studies that are well designed. The efficacy of using dietary counselling to improve outcome has not been investigated either.

55. Summary � evidence base ONS can effectively increase total energy, protein and micronutrient intakes. They tend not to substantially replace food intake ONS can produce significant clinical and functional benefits in some patient groups in hospital and in the community The benefits to outcome may be due to improved body weight and muscle mass or the critical supply of nutrients during recovery The current evidence base is incomplete, it needs to be regularly updated and developed So lets summarise the 4 main issues that we have addressed relating to the efficacy of ONSSo lets summarise the 4 main issues that we have addressed relating to the efficacy of ONS

56. �MUST� 1 year on Gradual adoption / implementation Frequently Asked Questions on BAPEN website Articles Symposia Training sessions and resources Translation into other languages MAG moving from �Advisory� to �Action�

57. In Summary Malnutrition in UK is common and costly Screening is a �MUST� �MUST� is a valid yet simple and quick to use tool suitable for use across all care settings Appropriate nutritional interventions can be effective in preventing and treating the problem

59. Lower boundary BMI (kg/m2) values ASPEN(2002) suggest <18.5 kg/m2 to indicate underweight in their report on evidence based best approach to practice of nutritional support OPCS in the UK uses <20kg/m2 to indicate underweight even in people of >75yr USA edition of Dietary Guidelines(1990) suggested age specific BMI reference ranges but withdrew in the 1995 edition Influence on mortality of confounding variables eg smoking, pre existing disease, drug and alcohol ingestion, poverty smoking and pre existing disease known to reduce weight and increase risk of premature death BMI is an attractive index because it is linearly related to fat and inversely related to the proportion of body weight due to lean tissues which carry out a variety of physiological functions and the proportion of body weight due to body fat, which is a risk factor for premature death. Relationship between BMI and body composition is only approx and is affected by gender, age and race. BMI is an index relating to risk and is not a diagnostic tool for malnutrition. It should be used to provide an approx guide to the probability or risk of PEM rather than to identify malnutrition per se. BMI has been recorded in a wide range of studies in relation to mortality and body function in a variety of circumstances. This makes possible a comparison of extensive amounts of data obtained from different parts of the world and different healthcare settings. ASPEN Board of Directors (2002)suggest 18.5kg/m2 to indicate underweight in their report on evidence based best approach to practice of nutritional support. The Office of Population Census and Surveys in the UK uses <20 to indicate underweight even in people >75yr. BMI is an attractive index because it is linearly related to fat and inversely related to the proportion of body weight due to lean tissues which carry out a variety of physiological functions and the proportion of body weight due to body fat, which is a risk factor for premature death. Relationship between BMI and body composition is only approx and is affected by gender, age and race. BMI is an index relating to risk and is not a diagnostic tool for malnutrition. It should be used to provide an approx guide to the probability or risk of PEM rather than to identify malnutrition per se. BMI has been recorded in a wide range of studies in relation to mortality and body function in a variety of circumstances. This makes possible a comparison of extensive amounts of data obtained from different parts of the world and different healthcare settings. ASPEN Board of Directors (2002)suggest 18.5kg/m2 to indicate underweight in their report on evidence based best approach to practice of nutritional support. The Office of Population Census and Surveys in the UK uses <20 to indicate underweight even in people >75yr.