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The role of the dietitian in optimising oral nutrition support strategies

The role of the dietitian in optimising oral nutrition support strategies. Anne Holdoway Consultant Dietitian Chair of the Multi-professional National Advisory Panel for ‘Managing Adult Malnutrition in the Community’ ’

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The role of the dietitian in optimising oral nutrition support strategies

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  1. The role of the dietitian in optimising oral nutrition support strategies Anne Holdoway Consultant Dietitian Chair of the Multi-professional National Advisory Panel for ‘Managing Adult Malnutrition in the Community’’ Education Officer – British Association for Parenteral & Enteral Nutrition (BAPEN) LONDON. June 2019

  2. A flavour of what is to come…. • The healthcare landscape • Malnutrition – size, complexity and skill sets for management • Dietitians – our role in debunking myths and what we offer • Threats to our toolkit – are ONS a marketing ploy or addressing a clinical need? • Real-world data and measuring what matters to patients and carers • Case studies – the good, the bad and the ugly • Future actions

  3. The Healthcare Landscape • Demands for healthcare are increasing • Ageing population • Long-term conditions affect 15 million people in England alone and account for 70 % of healthcare expenditure Department of Health (2012). Report. Long-term conditions compendium of Information: 3rd edition

  4. Malnutrition is prevalent across a wide variety of diseases Prevalence of malnutrition in hospital by diagnosis UK n = 9290 (‘MUST’ medium + high risk)1 The Netherlands n = 8028 (defined by BMI, undesired weight loss, nutritional intake*)2. Russell C, Elia M. Nutrition screening survey and audit of adults on admission to hospitals, care homes and mental health units. 2008. Redditch, BAPEN. Meijers JM, Schols JM, van Bokhorst-de van der Schueren MA, Dassen T, Janssen MA, Halfens RJ. Malnutrition prevalence in The Netherlands: results of the annual Dutch national prevalence measurement of care problems. Br J Nutr 2009; 101(3):417-423.

  5. Why is malnutrition so prevalent in the presence of disease and in ageing? • Disease itself may interrupt or reduce intake • Intake may be inadequate compared to requirements (malabsorption, increased energy expenditure) • Anorexia / loss of appetite / cachexia occur in ageing and in disease • Multi-morbidities (inflammatory conditions) increase muscle loss and hamper appetite. • Loss of muscle mass increases frailty risk. • The ability to source and prepare meals may diminish in illness and the elderly (including the motivation) • Protein requirements increase at a time intake often declines

  6. Malnutrition affects 3 million in the UK

  7. Malnutrition – facts & figures • Malnutrition accounted for: - 128,361 bed days 2010-2011- 184, 528 2015-2016 (source NHS England 2016) • Most (93%) is in the community. • The effects cost the UK £28 billion (Elia et al, estimates published in 2015) • With an ageing population and multi-morbidities the numbers ‘at risk’ may not change • Effective strategies might identify those affected or ‘at risk’ earlier.

  8. The cost per malnourished subject = £7,408 per year and per non-malnourished subject = £2,155 per subject per year.. The cost per malnourished subject = £7,408 per year and per non-malnourished subject = £2,155 per subject per year.. Elia (2015) http://www.bapen.org.uk/pdfs/economic-report-short.pdf

  9. Sli-doWhat are these costs due to? • The cost of nutrition support products – ONS/tube feeds • The cost of hospital admission/additional drugs • The cost of care in the community • The cost of social care

  10. Costs incurred as a consequence of malnutrition are due to: • Poor wound healing • Increased susceptibility to infection • Impaired mental and physical function • Reduced activities of daily living (ADL) • Increased readmissions • More GP visits • Increased length of hospital stay (> 30%) • Greater likelihood of admission to care homes Recent estimates for the cost of UK public expenditure (health and social care) associated with malnutrition = £28 billion (Wallace, BAPEN annual conference 2017) • Pirlich M et al C et al. Clin Nutr 2006; 25(4):563-572. • Cansado P, Ravasco P, Camilo M. J Nutr Health Aging 2009; 13(2):159-164. • de LD, Lopez GA. Eur J Intern Med 2006; 17(8):556-560. • Planas M et al , Clin Nutr 2004; 23(5):1016-1024. • Elia M, Stratton RJ, Russell C, Green CJ, Pang F. The cost of disease-related malnutrition in the UK and economic • considerations for the use of oral nutritional supplements (ONS) in adults. 2005. Redditch, BAPEN. • 6. Elia M and NIHR (2015) Economic report

  11. Is (mal)nutrition on our secretary of state for health’s agenda?

  12. Sli-do QuestionMalnutrition is real problem, affecting millions in the UK. How many times are dietitians (dieticians) / nutrition mentioned in the NHS Long Term Plan (long version)? • Once • 3 times • 5 times • > 10

  13. £28 billion - You gotta be kidding….....that’s a sh** load of money!!!

  14. The NHS Long Term Plan 2019 • Conscious prescribing • Increased use of generics • Stopping prescriptions for ‘low cost’ items • Reducing the need for health and social care through better self management

  15. When asked to evaluate inappropriate prescribing?

  16. Budget impact analysis involving implementation of the NICE clinical guidelines (CG32) and the NICE quality standard (QS24) on nutritional support Elia on behalf of NIHR 2015 http://www.bapen.org.uk/pdfs/economic-report-full.pdf

  17. Cost of nutrition support products = 2.5 % of total cost Image by Marna Pixabay

  18. Focusing on reduction in ONS may release short term savings.True savings are only feasible through full implementation of NICE CG32 and NICE QS 24

  19. It is the cumulative failure to identify, treat or prevent malnutrition that incurs considerable ‘costs’ to the healthcare economy. The cost per malnourished subject = £7,408 per year and per non-malnourished subject = £2,155 per subject per year.. Elia (2015) http://www.bapen.org.uk/pdfs/economic-report-short.pdf

  20. Tackling Malnutrition can save money but where do we focus our efforts? Average length of stay for all causes in the UK was 6.9 days in 2014 Source: www.nhsconfed.org/resources/key-statistics-on-the-nhs

  21. 93% of malnutrition exists in the community.If we focus our energy tackling it in hospitals… …we won’t fix the problem. Malnutrition develops insidiously in the community for many weeks before hospital admission. Nutrition rehabilitation may be required for months beyond the hospital episode

  22. Tackling the problem Dietitians n = 9,000 7,000

  23. Tackling malnutritionIn general practice, awareness is important • Every day, over 1 million people are cared for in General Practice • Taking action to screen and treat in pre-frailty & frailty clinics, and when managing those in the ‘at risk’ groups can prevent malnutrition – consider how you might engage community practitioners?

  24. To doctors weight loss is viewed as a red flag… …but is less commonly recognised as a modifiable entity that may influence disease outcome

  25. Knowledge • Debunking myths: • weight loss is an inevitable part of disease or ageing

  26. Malnutrition doesn’t just happen…it happens if you let it….

  27. Tackling Malnutrition • Nutrition should be an integral component of the management of LTCs (all too often it isn’t) • Members of the healthcare community need to help to establish risk using a validated screening tool • Dietitians and those up-skilled in nutrition should undertake a comprehensive nutrition assessment and develop an appropriate care plan

  28. (Mal)nutrition screening is only a starting point • Screening – assesses risk e.g. malnutrition risk ‘MUST’ • In those ‘at risk’ a more detailed assessment should take place • Assessment evaluates underlying issues, evaluates intake, identifies problems, determines type of malnutrition which in turn defines ‘potential’ goals and outcomes

  29. Underlying causes - fix the fixable • Bowel symptoms • Early satiety • Nausea • Swallowing problems • Reduced intake • Taste changes • Abdominal discomfort/abdominal pain • Isolation

  30. Setting goals for effective nutrition support • identify the aims before treatment starts • review at appropriate intervals • aims should be anticipatory and participatorytaking into account the patient’s condition, prognosis, patient’s desires

  31. Clinically & cost effective nutritional support should ... • Improve or maintain nutritional intake • Improve or maintain nutritional status • Improve or maintain function (ADLs, grip strength) • Improve clinical outcomes such as reduced complications, reduced mortality, reduced hospital readmission • Reduce healthcare use and costs • Be acceptable to the patient and carer

  32. What matters to the patient and/or carer? • Tolerance to treatment e.g. cancer • Healing of a pressure ulcer – to help regain confidence to go out of the home • Reducing risk of falls and ‘another’ hospital admission • Remaining independent, strong enough to go out / walk upstairs / sit in the garden. • Reducing (re)infection risk – polypharmacy / hospital admission • Preservation of self and identity - social life, work, physicality • Adding life to years not just years to life - Living life as best as possible

  33. Historically studies have focused on weight and dietary intake….

  34. And possibly failed to capture what Dietitians offer … • Consider all the challenges around food from client and carer perspective. • Educate and motivate • Individualise advice and think about context • Apply pragmatism • Set mutually agreed realistic goals to optimise ‘nutritional status’, enjoyment and QoL • Achieve dietary change that is enduring1,2 1. Weekes et al, 2009 Thorax;64:326–331 2. Ravesco et al,2005 Head Neck 27(8):659-68.

  35. Dietitian’s Weaknesses “What can I say about our dietetic service other than it takes ages for anyone to be seen, I get minimal information from them about why the patient may need an intervention, let alone what outcome they are aiming for and even then it tends to be weight gain or loss. These are not the outcomes I want to hear about. I can't afford to pay for that, I need to spend my limited money on services that keep patients out of hospital. “ GP Midlands (2012)

  36. There remains a lack of understanding by others of what we do and what we can achieveThere is the misunderstanding that one size fits all....and handing out an advice leaflet achieves the same www.kingsfund.org.uk/publications/ supporting -people-manage-their-health.

  37. Oral Nutritional Support options: fortifying food with protein, carbohydrate and/or fat plus minerals and vitamins; the provision of snacks and/or oral nutritional supplements as extra nutrition to regular meals, changing meal patterns or the provision of dietary advice to patients on how to increase overall nutrition intake by the above. NICE CG32 (2006)

  38. Nutrition counselling… ..by a health care professional is regarded as the 1st line of nutrition therapy. Professional counselling, as distinct from brief and casual nutritional “advice”, is a dedicated and repeated professional communication process that aims to provide patients with a thorough understanding of nutritional topics that can lead to lasting changes in eating habits. Arends J, et al., ESPEN guidelines on nutrition in cancer patients, Clinical Nutrition (2016)

  39. Dietary counselling acknowledges the many issues around dietary change • Diets are a habit of a lifetime - It takes time to change habits • Food can become a point of conflict and stress • Evaluates whether dietary advice to increase Calories using fat/sugar is acceptable1 • Puts public health messages into context(normal fat, normal sugar) • Anticipates the impact of delaying ONS i.e. would a prolonged ‘FOOD FIRST’ approach without timely review pose harm 1. Gronberg et al, 2005 JHND

  40. Dietitians can establish the type of malnutrition ter Beek L, et al. Clinical Nutrition (2016) http://dx.doi.org/10.1016/j.clnu.2016.03.023 2. Muscaritoli M et al Clinical Nutrition (2010) Apr; 29( 2) :154-9 3. Healy E,et al 2014 A systematic review Clinical Nutrition e-SPEN Journal Volume 9, Issue 3, Pages e109–e122

  41. Dietetic assessment and counselling requires realism • Deficit in those losing weight approx. 600 – 1000 Cals daily • As dietitians we should assess the likely increase in oral intake diet alone? • Is this sufficient to replete lost stores and prevent further weight loss? Are ONS required immediately – a skilled practitioner can predict the need for ONS • Whilst evidence is weak for the effectiveness of dietary advice in managing disease-related malnutrition 1,2 the importance of food and drink should not be overlooked, dietary advice may be required to deal with diet-related challenges 1.Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence based approach to treatment. Wallingford: CABI Publishing; 2003 2. Baldwin C, Weekes L Cochrane review 2012

  42. Despite best efforts to improve dietary intake, energy and nutrient intake may continue to fall short of requirements1,2,3,4 Oral nutritional supplements (ONS) can be of considerable value • Barton AD, Beigg CL, Macdonald IA, Allison SP. High food wastage and low nutritional intakes in hospital patients. Clin Nutr 2000; 19(6):445-449. • Walton K. Williams P, Tapsell L, Batterham M. Rehabilitation inpatients are not meeting their energy and protein needs. E-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 2007; 2:e120-e126. • Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence based approach to treatment. Wallingford: CABI Publishing; 2003. • Stratton RJ. Malnutrition: another health inequality? Proc Nutr Soc 2007; 66(4):522-529.

  43. Optimising use of ONS Dietitians know the difference Do others? Dietitians should lead on the development of resources to help others – Local formularies or https://www.malnutritionpathway.co.uk/library/ons.pdf

  44. Slido questionIn your locality are non Dietitians ‘allowed’ to prescribe ONS? • Yes • No • Depends

  45. Is part of our toolkit under threat ?Objections to ONS in the community • Patients should just eat more • Patients don’t gain weight • ONS suppress food intake • ONS make no difference to outcome • Patients don’t drink them • ONS are expensive

  46. When we are sick we are not hungry…. Despite best efforts to improve dietary intake, energy and nutrient intake may continue to fall short of requirements1,2,3,4 • Barton AD, Beigg CL, Macdonald IA, Allison SP. High food wastage and low nutritional intakes in hospital patients. Clin Nutr 2000; 19(6):445-449. • Walton K. Williams P, Tapsell L, Batterham M. Rehabilitation inpatients are not meeting their energy and protein needs. E-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 2007; 2:e120-e126. • Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence based approach to treatment. Wallingford: CABI Publishing; 2003. • Stratton RJ. Malnutrition: another health inequality? Proc Nutr Soc 2007; 66(4):522-529.

  47. Objections to ONS in the community • Patients should just eat more – a ‘sick’ patient may not be able to • Patients don’t gain weight • ONS suppress food intake • ONS make no difference to outcome • Patients don’t drink them • ONS are expensive

  48. Objections to ONS in the community • Patients should just eat more – a ‘sick’ patient may not be able to • Patients don’t gain weight – the goal might be avoiding weight loss • ONS suppress food intake • ONS make no difference to outcome • Patients don’t drink them • ONS are expensive

  49. Objections to ONS in the community • Patients should just eat more – a ‘sick’ patient may not be able to • Patients don’t gain weight – the goal might be avoiding weight loss • ONS suppress food intake • ONS make no difference to outcome • Patients don’t drink them • ONS are expensive

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