Managing Malnutrition
Andrea Ralph BSc (hons) RD
Senior Medical Affairs Advisor, Nutricia
Identifying malnutrition
NICE Clinical Guideline 32, 2006 section 1.2.1
Recommends screening across all care settings
Health care professionals should screen
All hospital inpatients on admission
All outpatients at there first appointments
All people in care homes on admission
All people on registration at GP surgeries
And all of the above upon clinical concern
Appropriate management of malnutrition
NICE Clinical Guideline 32, 2006
1.6.6
Healthcare professionals should consider oral nutrition support to
improve nutritional intake for people who can swallow safely and
are malnourished or at risk of malnutrition.
‘A-grade’ recommendation
… should contain a balanced mixture of nutrients (including protein, energy,
vitamins, minerals)
… should continue until the patient is established on adequate oral intake
from normal food
….take care when using food fortification as this tends to supplement
energy and not other nutrients
Why we should manage malnutrition
Adverse consequences for the patient
Muscle wasting (skeletal, cardiac, respiratory)
Reduced immune function - Increased risk of infection
Poor / delayed wound healing / pressure ulcers / reduced mobility
Apathy and depression
Reduced QOL, increased complications
Increased health care costs
(Stratton et al 2003)
Why we should manage malnutrition
Adverse consequences for the health economy
People with malnutrition have higher use of health care:
More GP visits (65%)
More hospital admissions (82%)
More hospital readmissions
More deaths post-discharge
More support post-discharge
(Elia 2005, Elia 2006, Stratton et al 2006)
NICE cost saving guidance – Dec 2009
Costs arising:
• improving systematic screening,
• assessment and treatment of malnourished patients.
CG32
Nutrition
support in
adults
If this guideline was fully implemented and resulted in
better-nourished patients:
• Reduced complications such as secondary chest
infections, pressure ulcers, wound abscesses and cardiac
failure.
• Reduced admissions
• Reduced length of stay for admitted patients
• Reduced demand for GP and outpatient appointments
-£28,472
Significant savings are possible.
3rd highest of 19 reviewed guidelines for potential cost saving per 100,000 people
Identifying and managing malnutrition
http://www.bapen.org.uk/must_tool.html
Malnutrition risk identified – what next?
Document screening details
Identify and manage reason for decreased nutrition intake
– Disease symptoms / side effects
Take action! Develop care plan (refer to local policy)
– Consider:
• Aims of intervention
• Short term / long term goals
– Route of intervention (oral / enteral / parenteral)
– Practicalities
Monitor progress and adapt care plan appropriately
– Weekly for all inpatients
Managing malnutrition
Consider route for
nutrition support
Non-functioning gut
Parenteral nutrition
Functioning gut
Absent or unsafe
swallow
Safe swallow
Enteral tube feeding
Oral nutritional
support
Enteral tube feeding
Enteral tube feeding
– NG
– Gastrostomy
Nutritionally complete
Wide range available for adults and children
Available in hospital and on prescription
In the community, home care nursing and delivery service
provided for patients
Involve a dietitian or nutrition support team
Oral nutrition support
Definition of : Oral nutrition support (NICE CG 32)
Practical support for people unable to feed themselves (e.g.
modified feeding aids), altered meal patterns (e.g. small meals and
snacks)
Fortified food with protein, carbohydrate, fat, vitamins, minerals
Dietary advice from a dietitian
Oral nutritional supplements (ONS).
Practicalities of improving oral intake
Assistance
– Ensure food ordered is the food received
– Assist with menu choices (high energy / modified texture where
required)
– Clear table of distractions
– Ensure table, food, utensils and drinks are within reach
– Offer assistance to cut up meals if needed
– Adapted cutlery / plates
Altered meal patterns
– Small meals and snacks (‘drip-feeding’ nutrition)
– Nourishing drinks
What is food fortification?
Adding everyday foodstuffs to meals to increase the nutrient
content, without increasing volume
– Butter, oil
– Full cream milk
– Cheese
– Skimmed milk powder
– Jam
– Syrup
– Honey
– Sugar
Caution – can increase just energy and protein without
micronutrients
Evidence – food fortification
Cochrane review, 36 studies (n=2614):
Evidence for nutrition support in malnourished adults:
– dietary advice
– no advice and
– dietary advice plus ONS in adults with malnutrition
Evidence suggests weight gain, grip strength, improved MUAC are
greater with dietary advice + ONS rather than dietary advice alone
‘lack of evidence for the provision of dietary advice in managing
illness-related malnutrition’
‘dietary advice plus nutritional supplements maybe more
effective than dietary advice alone or no advice’
Baldwin and Weeks 2009
There was insufficient evidence for NICE to assess
the effect of dietary advice and / or other food
strategies (snacks, food fortification) on mortality,
complications and weight
There was no data on the cost-effectiveness of these
approaches.
Dietary advice from a dietitian
Individual assessment and advice
– Meal pattern alteration
– Food fortification
– ONS
– Nutritional adequacy related to condition / nutritional requirements
Clinical indication e.g. renal disease, liver disease
Ideal for individuals where first line actions have not improved
nutritional intake
Preparation for discharge to home setting
Dietetic resource can vary from trust to trust
Check local policy
What are oral nutritional supplements (ONS)?
Produced by nutrition companies (range available)
Mostly liquids (some puddings)
Multi nutrient supplements
– Most are nutritionally complete
– Energy (fat and carbohydrate), protein, micronutrients)
– Milk, yoghurt, juice style ready made
Ready made usually gluten and lactose free
Available in hospital and on prescription (FP10)
Supplements you make up with milk
Supplements designed specifically for children
Some disease specific
Practicalities of using ONS
ONS (200-600kcal) can be used to improve clinical outcome in
a range of hospitalised patients.
(Stratton2007)
2 x standard 1.5 kcal/ml ONS
– 600-660kcal
– 24–28g protein
Consider individual preferences for flavour
– (sweet, savoury, fruit preferences)
ONS can be served chilled, at room temperature or warmed
From bottle with straw, decant into cup / beaker
Add to food
– Neutral / vanilla flavoured ONS in porridge, soups
– Dessert style served with ice cream
Ensure patient understands why they are receiving ONS and encourage
intake
NICE review of the evidence - oral
nutritional supplements
Proprietary oral nutritional supplements:
•Significantly reduce mortality
•Significantly reduce complications
•Significantly improve weight
•Functional benefits
•Better energy and protein intakes in supplemented
patients in all trials
•Acceptable to patients
Age UK ‘Still Hungry to be heard’
Update on the campaign launched 4 years ago
- 85% of hospitals engaged with the campaign
- 55% have taken action towards the 7 steps.
Age UK 7 steps to end malnutrition
1. Hospital staff must listen to older people, their relatives and carers and
act on what they say.
2. All ward staff must become ‘food aware’.
3. Hospital staff must follow their own professional codes and guidance
from other bodies.
4. Older people must be assessed for the signs or danger of
malnourishment on admission and at regular intervals during their stay.
5. Introduce ‘protected mealtimes’.
6. Implement a ‘red tray’ system and ensure that it works in practice.
7. Use volunteers where appropriate.
www.ageuk.org.uk
High Impact Actions for Nursing and Midwifery
8 ‘High impact actions’ identified by nurses and midwives
‘Keeping nourished getting better’ focuses on:
– identifying individuals at risk of malnutrition
– providing good nutritional care,
– stopping inappropriate weight loss and dehydration in NHS
provided care.
To ensure patients are screened for malnutrition and get the
right amount of nutrition and hydration needed for a speedy
recovery, dietitians and nurses need to work together.
http://www.institute.nhs.uk
Essence of Care:
Benchmarks for food and drink
10 factors in the food and drink section
Screening and assessment
Best Practice: People who are screened and identified at risk receive a
full nutritional assessment
Screening takes place on first contact with health care providers and is
repeated regularly for those at risk of malnutrition or upon clinical
concern.
Validated tool such as the Malnutrition Universal Screening Tool
(MUST)
A full assessment and appropriate referral is undertaken for people who
are identified initially as at risk of malnutrition or as morbidly obese.
Screening, assessment and nutrition support is undertaken in
partnership with people.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_119969
Summary
Nutritional screening using a reliable and valid tool, such as
‘MUST’, is an essential first step in the management of malnutrition
As part of the screening process, a plan for management of
malnutrition risk should be developed
There are a number of oral nutrition support strategies to improve
nutrition intake
Local policy should be in place for the appropriate evidence based
management of malnutrition
There is limited evidence for the use of dietary advice and food first
strategies in clinical practice
Evidence shows that ONS can improved clinical and functional
outcomes which may reduce health care costs.
Some Key References
NICE CG32. February 2006. Nutrition support in adults: oral nutrition support,
enteral tube feeding and parenteral nutrition. Includes Costing Report.
Elia M, Russell C (2009). Combating Malnutrition: Recommendations for
Action. Report from the advisory group on malnutrition, led by BAPEN.
Stratton RJ, Elia M. (2007). A review of reviews: A new look at the evidence
for oral nutrition supplements in clinical practice. Clinical Nutrition
Supplements (2); 5-23
Elia M. (2006). Nutrition and Health Economics. Nutrition (22); 576-578.
NICE CG32. February 2006. Nutrition support in adults: oral nutrition support,
enteral tube feeding and parenteral nutrition. Includes Costing Report.
Elia M, Stratton R, Russell C et al. (2005) The cost of disease-related
malnutrition in the UK and economic considerations for the use of oral
nutritional supplements (ONS) in adults. A report by The Health Economic
Group of The British Association for Parenteral and Enteral Nutrition
(BAPEN).
Baldwin C and Weeks CE (2009) Dietary advice for illness-related malnutrition
in adults (Review). Cochrane database of systematic reviews 2008, Issue 1.
Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidencebased approach to treatment. Oxford: CABI publishing, 2003.