Management of Malnutrition

1. Management of Malnutrition 8/12/10

2. Derby PCT recently produced and released: • Nutritional Management Algorithm for Effective Prescribing of Oral Nutritional Supplements (ONS) for Adults

3. MUST Score • MUST= Malnutrition Universal Screening Tool • Five-step screening tool to identify adults, who are malnourished, at risk of malnutrition or obese • Includes management guidelines which can be used to develop a care plan

4. MUST Score Step 1: • Measure height and weight to get a BMI and BMI score • BMI kg/m2 Score: • >20 (>30 Obese) = 0 • 18.5 -20 = 1 • <18.5 = 2 Step 2: • Note percentage unplanned weight loss in past 3-6 months and score using tables provided • Unplanned weight loss score: • <5 %= 0 • 5-10 %= 1 • %>10 = 2

5. MUST Score Step 3: • Establish acute disease effect and score • If patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days= Score 2 Step 4: • Add scores from steps 1, 2 and 3 together to obtain overall risk of malnutrition • Score 0 Low Risk • Score 1 Medium Risk • Score 2 or more High Risk Step 5: • Use management guidelines and/or local policy to develop care plan

6. Management based on MUST score • Low risk/Score 0: • Repeat screening • Care Homes : monthly • Community : annually for special groups e.g. those >75 yrs • Medium risk/Score 1: • Observe • Dietary intake record • Dietary advice including food fortification and OTC oral nutritional support

7. Dietary Advice • Eat Little and often and choose high calorie options where possible • 3 small meals plus 2-3 snacks or milky drinks (Horlicks, Ovaltine, Complan, Build up or milkshakes) • Bread, rice, pasta, cereal, chapatti or potatoes at each meal • Meat, fish, eggs, cheese, yoghurt, nuts, lentils or beans at each meal • Fruit, vegetables or fruit juice at each meal • Use a pint of full cream milk each day, fortified with 4 tablespoons of milk powder and use in place of ordinary milk for cereals, custards, sauces, drinks • 8 cups of fluid, include a variety of drinks

8. Dietary advice • Breakfast cereals – Add one or more of the following: fortified or evaporated milk, cream, yoghurt, fresh or dried fruit, nuts, syrup, honey or sugar. • Soups and sauces – Add one or more of the following: grated or cream cheese, cream, milk powder, fortified or evaporated milk, fried onions, margarine, butter, croutons or pasta • Potatoes and vegetables – Add one or more of the following: grated cheese, cream, margarine, butter, mayonnaise, salad cream or fried onions • Puddings and cakes – Add one or more of the following: cream, evaporated milk, custard, ice cream, jam, syrup, treacle, chocolate or fruit sauces, dried fruit.

9. Management based on MUST score • High risk/ Score 2: • Refer to dietician

10. Prescribing of Oral Nutritional Supplements • Nutritional suplements e.g. Fortisip, are borderline substances which can be prescribed as drug treatment if ACBS (Advisory Committee on Borderline Substances) standards are meet • Standard indications included: • Disease related malnutrition • Intractable malnutrition • Preoperative preparation of malnourished patients • Dsyphagia • Proven IBD • Following total gastrectomy • Short bowel syndrome • Bowel fistula

11. Thank you any questions?