nutrition versus malnutrition dietetics... · case study’s – practice . make every mouthful...
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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
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Whose responsibility is good nutrition?
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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
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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
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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
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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
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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)
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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
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Steps • BMI • Amount weight
loss • Current medical
condition • Add your MUST
score • Plan of care
MUST
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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?
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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
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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)
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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
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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.
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Case Study’s – Practice
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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
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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
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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
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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
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Consider what the treatment goals could be for Mr Brown and Mrs White?
Pureed diets
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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
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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.
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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
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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.
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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)
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6 Steps to appropriate Nutritional Care– Staffordshire Nutrition Support Guidelines
Step 4 – Achieving treatment goal
3 fortified meals – 2 snacks – 1 pint fortified milk
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Key Points Referral to dietitian if MUST 3 or 4 or if no improvement
3 meals – 2 snacks- 1 pint fortified milk
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Food first is common sense not science
Aim to increase calories in the same
quantity of food
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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
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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 [email protected] 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