make every mouthful matter dietitians - ssotp make every mouthful matter

Make Every Mouthful Matter

Dietitians - SSOTP


Aim of session

• Share the Staffordshire Nutrition Support Guidelines.

• Discuss making every mouthful matter - what is food fortification? why bother?

• Consider whether current puree/ soft diet provided in you care home is nutritionally complete?

• Ensure appropriate use of supplements



Whose responsibility is good nutrition?

6 Steps to Appropriate Nutritional Care – Staffordshire Nutrition Support Guidelines


1. Identification of Nutritional Risk (Calculate MUST)2. Assess the underlying cause of malnutrition3. Set clear treatment goals and document in the

patient record4. Make every Mouthful Matter – offer food first advice5. Review – Prescribe oral nutritional supplements if no

change6. 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)

Equipment required for adequate screening

• Calibrated scales - preferably seated – Class III• MUST tool information• Food and fluid charts• Measuring tapes


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


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

=MUST Score (probability of being malnourished)

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


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


Mr Brown80 year old manWeight 50kg, Height 1.7m, BMI 17.3kg/m² Recently in hospital following a strokeSpeech and language therapist advised - pureed diet and thickened fluidsIn the last month since returned to home has lost 5kg

MUST score = 3


6 Steps to Appropriate Nutritional Care– Staffordshire Nutrition Support Guidelines

Step 2 – Assess the underlying 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



Step 3 – Set clear treatment goals and document in the patient record• Target weight or target weight gain/ BMI• Wound healing if relevant• Weight maintenance where weight gain is

unrealistic


Consider what the treatment goals could be for Mr Brown?



Step 4 – Make every mouthful matter

3 fortified meals – 2 snacks – 1 pint fortified milk


Fortifying meals

– Full fat milk– Skimmed milk powder– Cream– Butter/margarine/oil– Cheese– Sugar/honey/jam/syrup– Peanut butter/Nutella– Mayonnaise/salad cream


1 pint of fortified milk per dayFortified milk =

1 pint full fat milk with 4 tablespoons skimmed milk powder added

Gives 600kcal and 40g protein in 1 x pint

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


Ordinary DietFood 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


Adapted DietFood Eaten Calories Protein

Breakfast Porridge (made with full-fat fortified milk)

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 fortified mash, peas, tinned peaches

490 32

Supper Malted Drink with 200ml fortified milk

225 13

Total 1665 76

Calorie Difference

995 30


Pureed diets


Pureed diets

Evidence shows that average intake of people given an unfortified pureed diet 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 peopleCaroline Walker Trust – Eating well for older peopleCaroline Walker Trust – Eating for older people with dementia

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.


Improving Pureed Diets

• Make sure a pureed diet is clinically necessary. • Make food as attractive as possible.– Piping bag or food moulds.– Vibrant colour combinations.– Use sauces (eg. cranberry sauce; raspberry coulis).

• Maximize the flavour of food (eg. condiments).


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)


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)


Don’t forget about snacks!

- Use soaking solutions for bread, cream crackers, biscuits and cake.

- Pureed fruit or pure juice.- Custard- Smoothies or milkshakes- Ice cream & jelly (only if

allowed unthickened fluids).



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

oral nutritional supplements• Assuming patient fits prescribing criteria


Comparison of Products

Milk shake style supplements, 330 calories and 13g proteinV

½ pint fortified milk, approx 300 calories and 20g protein

Crème pudding, 125g pot, 171 calories and 7g proteinV

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

Juice based supplements, 300 calories, 13g proteinV

1 x pint orange juice – 300 calories

Vitamin and mineral intake should be considered



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


How to Refer to Dietetics • Stafford Dietitians: Stafford and Stone, South Staffs, Cannock• See referral Form Tel: 0300 1240109

• Sir Robert Peel Dietitians: Tamworth, Lichfield– See Referral Form Tel: 01827 263800

• Waistlines : Cannock, Stafford and Surrounds, South Staffs, Lichfield, Tamworth, East Staffs– See Referral Form Tel: 01543 509740

• University Hospitals North Midlands Staffordshire Dietetic Team: Royal Stoke University Hospital: 01782 676030

• East Staffordshire: Burton-on-Trent - See Referral Form - Tel: 01283 507 160

Staffordshire Nutritional Support Guidelines and referral forms

http://www.staffordshireandstokeontrent.nhs.uk/Services/e.htm





make every mouthful matter dietitians - ssotp make every mouthful matter

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