nutrition versus malnutrition dietetics... · case study’s – practice . make every mouthful...

Nutrition versus Malnutrition

SSOTP – Dietitians

https://www.staffordshireandstokeontrent.nhs.uk/Services/Malnutrition-make-every-

mouthful-matter.htm

Make Every Mouthful Matter

Aim of the Session

• Improve knowledge - causes and consequences of malnutrition

• Increase awareness of Stafford Nutrition Support Guidelines – referral to dietitian

• Empower carers to ensure patients receiving adequate nutrition/ hydration

• Ensure care staff are able to calculate MUST score and based on MUST score set a treatment goal

Make Every Mouthful Matter

Whose responsibility is good nutrition?

Make Every Mouthful Matter

Malnutrition Facts - BAPEN

3 Million, 19.2 billion, 30-35% • 3 million adults are malnourished in UK and

many more at risk. • In 2011-12 malnutrition cost £19.2 billion total in

health and social care • It occurs in all healthcare settings – 30% of

adults admitted to hospital and 35% in care settings are malnourished

Make Every Mouthful Matter

Causes of Malnutrition Dislikes meals

Different meal environment

Lack of assistance at meal-times

Difficulty with feeding

Depression/ Anxiety/ Apathy

Medical condition

Malabsorption

Pain

↑ Energy needs

Medication

Loss of appetite/ altered taste

Make Every Mouthful Matter

Effects of Malnutrition Longer wound healing

Development of pressure ulcers

Feeling cold-difficulty getting warm

Confusion- reduced memory

General Tiredness and Fatigue

Muscle weakness

Falls

Immobility

Low Mood

Reduced immune system – more illnesses and infections

Make Every Mouthful Matter

Fluids and Dehydration Aim: 30-35ml of fluid per kg of body weight per day

45kg (7 stone) approx 1.5litres daily 64kg (10 stone) approx 2.2 litres daily

Dehydration is higher in older people: • Reliance on drinks being provided • Forgetting to ask • Forgetting to drink • Worry about getting to toilet on time/ waking at night

Make Every Mouthful Matter

Effects of Dehydration Urinary tract infection (UTI) Reduced urine output – colour

Reduced skin elasticity Unpleasant taste in mouth

Drowsiness Confusion

Lower Blood Pressure Falls

6 Steps to appropriate Nutritional Care – Staffordshire Nutrition Support Guidelines

1. Identification of Nutritional Risk (Calculate MUST) 2. Assessment of Cause of malnutrition 3. Clear treatment goals should be documented on the

patient record 4. Make every Mouthful Matter – offering food first

advice 5. Review – Prescribe oral nutritional supplements if no

change 6. Treatment goal met? Review and discontinue oral

nutritional supplements

6 Steps to appropriate Nutritional Care – Staffordshire Nutrition Support Guidelines

Step 1-Identification of Nutritional Risk (Calculate MUST)

Make Every Mouthful Matter

Malnutrition Universal Screening Tool - MUST

• Looks at body weight, height and percentage weight loss • Rapid or regular weight loss is a cause for concern • BMI under 18.5 should prompt investigation BUT may be

normal for this person

Make Every Mouthful Matter

Steps • BMI • Amount weight

loss • Current medical

condition • Add your MUST

score • Plan of care

MUST

Make Every Mouthful Matter

Step 1 – BMI score

• Need weight in kg or Stones

• Need Height in meters or feet

Example:

Weight 55kg, Height 1.62m

What is BMI?

Make Every Mouthful Matter

Step 2 – Weigh Loss Score

• All you need - weight! And amount lost! (in KG) over 3-6 months

• Was 58 kg 3 months ago now 55 kg - loss of 3kg in 3

months – see table for score

Step 3 Acute Disease Effect Score

• Patients who are acutely ill AND have had or are likely to have no nutritional intake for more than 5 days

• Most likely to apply to patients in hospital (particularly acute hospitals)

• Add 2 to score

Add Scores together • BMI Score • Weight Loss Score • Acute Disease Effect Score

=MUST Score Follow Staffordshire Nutrition Support Guidelines to develop care plan and to give advice

Staffordshire Nutrition Support Guidelines

If there is a MUST Score of 2 move to STEP 2 – commence pathway MUST score of 3 or more refer to Dietetic Service (and also commence pathway) Also refer to dietitian if: On ONS as sole source of nutrition Require artificial nutritional support e.g. Nasogastric/ Percutaneous Endoscopic Gastrostomy

Make Every Mouthful Matter

What if I Can’t get a Height or Weight?

• If height cannot be measured • Use recently documented or self-reported height (if

reliable and realistic). • If the subject does not know or is unable to report

their height, use one of the alternative measurements to estimate height (ulna length is recommended).

ALTERNATIVE MEASUREMENTS height from ulna length

Measure between the point of the elbow (olecranon process) and the midpoint of the prominent bone of the wrist (styloid process) (left side if possible)

Make Every Mouthful Matter

If height and weight cannot be obtained • Use mid upper arm circumference (MUAC)

measurement to estimate BMI category.

ALTERNATIVE MEASUREMENTS: Estimating BMI from mid upper arm circumference

The subject’s arm should be bent at the elbow at a 90 degree angle, with the upper arm held parallel to the side of the body. Measure the distance between the bony protrusion on the shoulder (acromion) and the point of the elbow (olecranon process). Mark the mid-point.

Ask the subject to let their arm hang loose and measure around the upper arm at the mid-point, making sure that the tape measure is snug but not tight.

If MUAC is <23.5 cm, BMI is likely to be <20 kg/m2

If MUAC is >32.0 cm, BMI is likely to be >30 kg/m2

Subjective Criteria

• In some patients - may not be possible to obtain height, weight or BMI

In these circumstances:

• Other subjective criteria can be used to assist your professional judgement of the patient’s nutritional risk category

• This is not designed to assign a score

Make Every Mouthful Matter

Subjective Criteria - weight loss Step 1 - BMI • Clinical impression – thin, acceptable weight,

overweight. • Obvious wasting (very thin) and obesity (very

overweight) can also be noted Step 2 - Unplanned weight loss • Clothes and/or jewellery - loose fitting (weight loss). • History of decreased food intake, reduced appetite or

swallowing problems over 3-6 months and underlying disease or psycho-social / physical disabilities likely to cause weight loss.

Make Every Mouthful Matter

Case Study’s – Practice

Make Every Mouthful Matter

Mr Brown 80 year old man Weight 50kg, Height 1.7m Recently in hospital following a stroke Speech and language therapist advised - pureed diet and thickened fluids In the last month since returned to home has lost 5kg

Calculate MUST score

Make Every Mouthful Matter

Mrs White

72 years old Weight 50kg Weight 6 months ago was 54kg Mrs White doesn’t know her height and is very unsteady on her feet Ulna length 23.5cm Mrs White is relatively well, has small portions at meal-times

What is her MUST Score

Make Every Mouthful Matter

6 Steps to appropriate Nutritional Care– Staffordshire Nutrition Support Guidelines

Step 2 – Assessment of cause of Malnutrition • Ability to chew and swallowing issues • Impact of medication • Physical symptoms e.g. nausea, vomiting, constipation • Environmental and social issues • Psychological issues • Tissue viability/ skin integrity

6 Steps to appropriate Nutritional Care– Staffordshire Nutrition Support Guidelines

Consider the cause of malnutrition in

Mr Brown ? Mrs White ?

Step 2- Assessment Cause of Malnutrition

Make Every Mouthful Matter

6 Steps to appropriate Nutritional Care– Staffordshire Nutrition Support Guidelines

Step 3 – Clear treatment goals should be documented on the patient record

• Target weight or target weight gain/ BMI • Wound healing if relevant • Weight maintenance where weight gain is unrealistic

Make Every Mouthful Matter

Consider what the treatment goals could be for Mr Brown and Mrs White?

Pureed diets

Make Every Mouthful Matter

Pureed diet

Evidence shows that average intake of people given pureed diet which is not fortified is about 800kcals/ day

Men Women

Energy - EAR 2100kcals 1810kcals

Protein - RNI 53.3g 46.5g

COMA report Dietary reference Values for food Energy and Nutrition in the UK for older people Caroline Walker Trust – Eating well for older people

Make Every Mouthful Matter

What do consumers think of pureed food?

(2014). Journal of Nutrition in Gerontology and Geriatrics, 33:139-159.

- Food are indistinguishable from one another. - Variety is lacking. - Inconsistent appearance/texture. - Want “special” food for birthdays & celebrations. - Want to eat in private.

Make Every Mouthful Matter

Pureed Diet

• Make sure puree diet is necessary – consult with speech and language therapist

• Keep separate foods and flavours apart – to make food as attractive as possible

• Use herbs, spices, strongly flavoured ingredients to make puree diet appetising

Make Every Mouthful Matter

Improving Pureed Diets

• Make sure staff know what the foods are and can describe them to the resident.

• Use recipes to promote a consistent product. • Provide a choice for sauces and condiments.

• Vary the temperature of the foods and the flavour (eg.

sour, tangy) and account for decline in sense of smell which alters taste.

Make Every Mouthful Matter

High Calorie Liquids for Pureeing

• Sauces –cheese, parsley, dill, tartar, cheesy tomato or white sauce

• Creamy soups • Full-fat fortified milk • Full-fat yoghurt or greek yoghurt • Crème Fraiche/double cream/sour cream • Coconut milk (tinned)

Make Every Mouthful Matter

6 Steps to appropriate Nutritional Care– Staffordshire Nutrition Support Guidelines

Step 4 – Achieving treatment goal

3 fortified meals – 2 snacks – 1 pint fortified milk

Make every mouthful matter

Make Every Mouthful Matter

Fortifying the diet

• Maximise goodness in each meal • Fortify diet using -

• high energy/ protein foods, e.g. skimmed milk powder, cream, butter, cheese, sugar, honey, oil

• Puree foods with milk, cream or gravy but not water

Make Every Mouthful Matter

Food/Fluid fortification

Food Quantity Calorie/ Protein Butter 1 pat 70 kcal Double Cream 50ml 225 kcal Olive oil 1 tbsp 99 kcal Mayonnaise 1 tbsp 128 kcal Sugar 1 tbsp 80 kcal Jam 1 tbsp 40 kcal Skimmed Milk Powder 1 tbsp 22g protein/ 118 kcal Cheese 25g 6g protein/ 104 kcal

Make Every Mouthful Matter

Nourishing Drinks

1 pint of fortified milk a day 1 pint full fat milk with 4 tablespoons skimmed milk powder

added

Gives 600kcal and 40g protein in 1 x pint

Use in milkshakes/ smoothies Malted drinks, tea, coffee made with whole milk

Make Every Mouthful Matter

Ordinary Diet

Food Eaten Calories Protein Breakfast Porridge (milk and water) 135 5 Mid morning Coffee 15 1 Lunch Vegetable Soup and roll 220 7 Mid afternoon Tea 15 1 Dinner Poached fish, 1 x scoop

mash, peas, tinned peaches 270 31

Supper Coffee 15 1 Total 670 46

Make Every Mouthful Matter Adapted Diet

Food Eaten Calories Protein Breakfast Porridge (whole milk and 1 x

tbsp double cream) 330 8

Mid morning Milky Coffee (200ml fortified milk)

200 13

Lunch Cream of Vegetable Soup and roll with butter

335 8

Mid afternoon Tea and biscuit 85 2 Dinner Poached fish, 1 x scoop mash

with butter and skimmed milk powder, peas, tinned peaches and cream

490 32

Supper Malted Drink with 200ml fortified milk

225 13

Total 1665 76 Calorie Difference

995 30

Make Every Mouthful Matter

Comparison of Products

• ½ Pint fortified milk approx 300 calories and 20g protein • Ensure drink bottle 330 calories and 13g protein • Ensure Crème pudding, 125g pot, 171 calories and 7g

protein • Thick and creamy yoghurt, 125g pot, 200 calories and 7g

protein • Ensure plus juce – 330 calories • 1 x pint orange juice – 300 calories

Vitamin and mineral intake should be considered

Make Every Mouthful Matter

Over the Counter

• ‘Complan’/ ‘Meriten’ milk shakes and soups as powder to be mixed up

• ‘Nurishment’ drinks in cans and bottles, ready mixed, just open and drink

Vitamin and mineral intake should be considered

Make Every Mouthful Matter

6 Steps to appropriate Nutritional Care– Staffordshire Nutrition Support Guidelines

STEP 5 – Review: • If food first approach has failed – prescribe oral

nutritional supplements • Assuming patient fits prescribing criteria

Make Every Mouthful Matter

GP Guidance for Prescribing (ACBS)

• Products are recommended on the basis that they may be regarded as drugs for the management of specified conditions

• Doctors should satisfy themselves that the products can be safely prescribed and that patients are adequately monitored

Make Every Mouthful Matter

The criteria for prescribing

• Disease related malnutrition • Intractable malabsorption • Pre-operative preparation of malnourished patients • Dysphagia • Proven inflammatory bowel disease • Following total gastrectomy • Short Bowel Syndrome • Bowel fistula

Most residents will not meet these criteria

Make Every Mouthful Matter

6 Steps to appropriate Nutritional Care– Staffordshire Nutrition Support Guidelines

STEP 6 – Treatment goal met – review and discontinue • Review regularly to monitor • Assess continued need for supplements • When goals of treatment met discontinue oral nutritional

supplements

Make Every Mouthful Matter

Key Points Referral to dietitian if MUST 3 or 4 or if no improvement

3 meals – 2 snacks- 1 pint fortified milk

Make every mouthful count

Food first is common sense not science

Aim to increase calories in the same

quantity of food

Make Every Mouthful Matter

Conclusion

• Malnutrition can be prevented through screening • Early detection leads to brighter outcomes both for

residents and carers • A well nourished resident could possibly need less

manual assistance, be more independent • Food first principles can be passed on by you to anybody

in care or in the community

Make Every Mouthful Matter

How to Refer to Dietetics

Dietetic hub contact details: Specialist Dietetic Service Staffordshire & Stoke On Trent NHS Partnership Trust Rear Block C, Beecroft Court Beecroft Road Cannock WS11 1JP ssotp.adultdietetics@nhs.net Phone : 0300 124 0355 GoldFax: (01543) 465111 Website to access referral forms/ guidelines and make every mouthful matter information: http://www.staffordshireandstokeontrent.nhs.uk/Services/dietetics_2.htm